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THE 

UEINE AND FECES 
IN DIAGNOSIS 



BY 



OTTO HENSEL, Ph.G., M.D., 

BACTERIOLOGIST, GERMAN HOSPITAL, NEW YORK, 

AND 

RICHARD WEIL, A.M., M.D., 

PATHOLOGIST, GERMAN HOSPITAL, NEW YORK, 

IN COLLABORATION WITH 

SMITH ELY JELLIFFE, M.I)., PhD., 

INSTRUCTOR IN PHARMACOLOGY AND THERAPEUTICS, COLUMBIA UNIVERSITY; 
VISITING NEUROLOGIST, CITY HOSPITAL, NEW YORK. 

ILLUSTRATED WITH 116 ENGRAVINGS AND 10 COLORED PLATES. 




PHILADELPHIA AND NEW YORK 

LEA BROTHERS & CO. 

1905 



LIBRARY of CONGRESS 
Two Copies Received 

JAN 4 J 905 
^Jopynsmt Entry 

CL*SS // XXc, Noi 
COPY / B. 






Entered according to the Act of Congress in the year 1905, by 

LEA BROTHERS & CO. 
In the Office of the Librarian of Congress. All rights reserved. 



PREFACE 



Large and exhaustive treatises on clinical and laboratory meth- 
ods of diagnosis are numerous, but a compact, handy and trust- 
worthy guide to the combined study of the urine and the feces is 
still a desideratum. It has been the aim of the authors to supply 
this, bearing in mind throughout the actual daily needs of the 
working practitioner. 

The importance of nrinary examination for purposes of diag- 
nosis of diseases of the kidneys, as well as for general perversion of 
bodily functions, needs no special comment. Every practitioner of 
medicine or surgery makes use of urinalysis. It has been the 
object of Dr. Hensel in preparing the chapters on the urine, so to 
present this many-sided subject that the required diagnostic indi- 
cations may be obtained with the minimum of effort compatible 
with accuracy. However, the more technical procedures have not 
been omitted, nor have the needs of the advanced student of urin- 
ology been neglected. 

The presentation of the accumulated knowledge concerning the 
feces in the chapters upon that subject, which are largely from the 
pen of Dr. Weil, must prove of great clinical value to every prac- 
titioner of medicine. The systematic study of the feces has been 
much neglected by physicians, pediatrists alone evincing a com- 
mensurate interest in this branch of diagnostic medicine. Prob- 
ably this has been due in large part to a scanty and scattered liter- 
ature ; but, thanks to the unremitting labor of German investiga- 
tors, notably Schmidt and Strasburger, some order has been 
brought out of the chaos of coprologic research, and in the present 
volume, for the first time, many important facts are rendered acces- 
sible to English-speaking students. 

(iii) 



iv PREFACE. 

i We are particularly indebted;, in the chapters on Bacteriology, to 
the masterly work of Ford, done largely under the auspices of the 
Rockefeller Research Fund. His investigations have laid the 
foundation of a thorough knowledge of the intestinal bacterial 
flora, and the results of his work have been closely followed in this 
manual. 



CONTENTS 



URINALYSIS 



CHAPTER I. page 

General Pathology and Physiology of the Kidneys. The Mechanism 

of Urinary Secretion . ; 17 

CHAPTER II. 

Physical Properties of Urine 20 

CHAPTER III. 
Ciifm istry of Urine 3G 

CHAPTER IV. 
The Ap.normal Constituents of the Urine and their Significance .... 43 

CHAPTER V. 
Chemical Tests for Normal Constituents 53 

CHAPTER VI. 
Qualitative and Quantitative Tests for Abnormal Constituents. ... 72 

CHAPTER VLL 
Renal and Bladder Stones Ill 

CHAPTER VIII. 
Microscopical Examination of Urine 113 

CHAPTER IX. 
Bacteriology of Urtne 135 

CHAPTER X. 
Preservation of Urine 142 

CHAPTER XL 
Functional Efficiency of Kidneys 147 

(v) 



vi CONTENTS. 

CHAPTER XII. 
Cri nary Diagnosis 152 

CHAPTER XIII. 
Reagents Necessary eor Urinalysis 154 



THE FECES 

CHAPTER XIV. page 

Macroscopic Examination of the Feces 157 

CHAPTER XV. 
Microscopical Examination of the Feces 177 

CHAPTER XVI. 
Bacteriological Examination of Feces 204 

CHAPTER XVII. 
Animal Parasites — Pathological Forms 204 

CHAPTER XVIII . 
Chemical Examination of Feces 294 

CHAPTER XIX. 
Characteristic Pictures in Disease 313 



COMPARATIVE SCALES, showing at a glance the exact equivalent oi 
ordinary weights and measures in those of the Metric System, and vice versa. 



CENTIGRADE 


FAKRENHE 


SCALE 




SCALE 




-= 


Z — 107 


41- 




- — 106* 




J 


- — 105° 




z 








— 101° 




z 








- 103" 




- 




39- 




= 102 r 




z 






~z 


101* 


38 1 








E 


= 100 c 






1 




- 


99° 


37 1 
















z — 98 






z 


86- 




5—97° 






- 






= — 96° 






- 


35- 




- — 95° 



FLUID 




CUBIC 
C ENTI METERS 





8- 
9- 
10- 
11- 
12- 
13- 
14- 
15- 
Ipirit =16- 



OUNCES 


GRAM 




- ( 


1 








2 


~ 


3 




4 




5 








7 




8 






z 


10 


- 


11 


— 


X»=12 


z 







MINIMS 

0" 



500 

CUBIC 
C ENT IMETERS 



13 = 20- 



FLUIC 
DRACHMS 



40- 

50- 

l/l.dr.=60- 

70- 



l/Uz.^8- 



DECIGRAMS CENTIMETERS 



URINALYSIS. 



CHAPTER I. 



GENERAL PATHOLOGY AND PHYSIOLOGY OF THE KIDNEYS. 
THE MECHANISM OF UEINARY SECRETION. 

The parts of the kidney immediately associated with the secre- 
tion of urine are the glomerular capsule, the convoluted tubes and 
the loop of Itenlo, while the straight collecting tubules probably 
have no secretory functions. The most complex portion of this 
tract is the glomerulus. It consists of an afferent vessel, which 
breaks up into a number of capillaries to form an intricate mesh- 
work, the separate vessels of which again unite to form an efferent 
vessel. The capsule is an expansion of the uriniferous tubule, and 
consists of two layers, the inner one of which closely invests the 
tuft of capillaries, and is made up of a single layer of flattened 
endothelial cells. 

It is evident that most favorable conditions exist here for filtra- 
tion. The blood-stream is considerably slowed, owing to the width 
of the stream-bed, and the blood itself is separated from the 
capsular space by only two layers, the capsular and the glomerular 
endothelium. 

In accordance with the fact that the secretory apparatus of the 
convoluted tubules and the loops of Henle remove different sub- 
stances from the blood than the glomeruli, tbo cells interposed 
between blood and urine here present a different structure. They 
are generally cuboidal or cylindrical ami granular in appearance, 
and show a peculiar striation toward their base. In the collecting 
tubules the lining cells are clearer; they increase in thickness as 
they approach the apex of the papilla, and are probably less highly 
differentiated cells. 

With the advance of physiological methods of research, theories 
relating to the mechanism of urinary secretion have undergone 
several modifications. While formerly simple mechanical tiltra- 



IS 



EXAMINATION OF URINE. 



tion was called upon to explain the formation of urine, it is now 
generally assumed that the cells lining glomeruli and tubule pos- 
sess active secreting properties. Luclwig formerly believed that 
water, inorganic salts and organic principles were simply filtered 
out of the blood by the glomeruli, the complete, but diluted, urine 
then becoming concentrated in the subsequent passage of this 
liquid along the convoluted tubules. Later physiological and 
histological study, however, seems to point to the fact that the 

Fig. 1. 



f.**> 



V 




Afferent 
and 
efferent 
vessels 




! Convo- 
luted 
tubules 



\ 



Bowman* s 
-eapsule, 
outer part 




Beginning of 

urinary 

tubule 



From a section through the cortex of an ape's kidney. A Malpighian corpuscle, together 
with the beginning of the urinary canal, is shown. X 350. (Szymonowicz.) 



larger amount of nitrogenous matter is actively eliminated by the 
cells of the convoluted tubules. Briefly, this theory is based upon 
the following observations: In birds uric acid takes the place of 
the urea of mammals. If the ureters are ligated, uric acid crystal- 
lizes out in the tubes, but never in the Malpighian corpuscles. 
Similarly, indigo-carmine, when injected into the circulation of a 
living animal, will be precipitated in the tubular cells. 



PATHOLOGY AND PHYSIOLOGY OF THE KIDNEYS. 



19 



Certain histological changes in these cells have, furthermore, 
been described by various authors which point to metabolic activity 



Fig. 2. 




Diagram showing the course of the renal tubules within the kidney. (Klein.) A, cortex; 
a, subcapsular portion destitute of Malpighian bodies; a', inner portion, also devoid of Mal- 
pighian bodies. B, boundary. C, portion of the medulla at the base of the pyramid. 1, Bow- 
man's capsule surrounding the glomerulus; 2, neck of the capsule and beginning of the 
uriniferous tubule; 3, first convoluted tubule; 4, spiral portion of the first convoluted tubule 
in the medullary ray; 5, descending limb of Henle's tube ; 6, Henle's loop; 7, 8, 9, ascending 
limb of Henle's tube; 10, irregular transition to the second convoluted tubule; 11, second 
convoluted tubule; 12, transition from second convoluted tubule to the collecting tubule ; 
13, 14, collecting tubule, joined below by others to form the excretory duct, which opens at 
the apex of the pyramid. 

more pronounced than would accompany the simpler processes of 
filtration and diffusion. Secretory function on the part of the 



20 



EXAMINATION OF URINE. 



glomerular endothelium is also highly probable, since many patho- 
logical products, such as albumin, hemoglobin and sugar-, are 
excreted here. 

The kidneys are richly supplied with nerves, chiefly of the sym- 
pathetic plexus. But their relation to the process of secretion is 
not well understood, since all stimulation produces alterations in 




Sketch of a Malpighian body from kidney of a rabbit ; <t, interlobular artery ; b, afferent 
vessel; c, capillary springing from afferent vessel; d, Bowman's capsule, with epithelial 
lining reflected upon the surface of the glomerulus; e. cavity of the capsule into which the 
watery constituents of the urine are first discharged; /, beginning of a uriniferous tubule ; 
g, convoluted tubules of the labyrinth. Between these tubules and the capsule are capillary 
bloodvessels derived from the efferent vessel (which is not shown, but emerges from the 
capsule near the afferent vessel, on a different level from that represented >. These and other 
structures are held in place by an areolar tissue, containing lymphatic spaces, some of which 
are represented. (Dunham.) 



vascular tension, which alone would explain changes in secretion. 
Direct connection between nerve-fibres and epithelial cells has not 
yet. been demonstrated, and it is probable that the nervous system 
affects renal function solely through the vessels. 

It is evident that an examination of the urine will aive a fairlv 



PATHOLOGY AXD PHYSIOLOGY OF THE KIDNEYS. 



21 



clear idea of the condition of the kidneys, but it is not only in renal 
disease that urinalysis is of extreme, indispensable value. While 



Fig. 4. 




FiC4. 5 




Sections from a rabbit's kidney, made perpendicular to the course of the straight tubules. 

Fig. 1. Through a portion of the pyramid: n, lower portions of the collecting tubules 
(excretory ducts) ; b, Henle's loop in tangential section ; c, capillary bloodvessels ; d. lymph- 
atic ; e. descending limb of Henle's tube. (Dunham. ) 

Fig. 5. Through part of a medullary ray and the adjoining labyrinth ; a, a, a, a, convo- 
luted tubules in the labyrinth; 6, spiral tubule; c, descending limb of Henle's tube; d, ascend- 
ing limb of Henle's tube: e. irregular tubule; /, collecting tubule; g, capillary bloodvessel. 
(Dunham.) 



the presence of albumin will in many cases point to a grave kidney 
lesion, the intimate relation of the organs with the cardio-vascular 



22 EXAMINATION OF URINE. 

system makes a close analysis in circulatory disturbances equally 
as imperative. Owing to the fact that the kidneys filter out 
foreign elements, or an excess or diminution of normal elements 
from a fluid which has come into intimate contact with all the 
organs of the body, the presence or absence of constitutional dis- 
ease, or of disease in some distant organ, may often be disclosed. 
It cannot be impressed too strongly upon the practitioner that no 
patient should leave his office without a thorough, if not complete, 
urine examination. How often does a headache form one of the 
symptoms of nephritis ; an excess of uric acid point to a gouty 
disturbance, and a cataract to diabetes. The probabilities of 
typhoid may be considerably increased in doubtful febrile condi : 
tions, and an excess of indican may materially assist in the diag- 
nosis of an intestinal obstruction. The surgeon may successfully 
diagnose a doubtful hematuria as tuberculosis or tumor where all 
physical signs fail, and by means of ureteral catheterization he 
may even decide on which side the lesion is. 

Fig. 6. 








Cloudy swelling of renal epithelia. (After Futterer.) 

On the other hand, too much should not be expected from 
laboratory technique. Many of the foreign elements found are 
common to several disorders, and while diagnosis may be materially 
assisted, it will not always be absolutely cleared up. In this age 
of accurate laboratory work there is a growing tendency to lay 
considerable stress upon the disturbed excretion of inorganic salts 
in constitutional disorders, but it is doubtful if this subject is as 
yet ripe for practical application. In another respect urinalysis 
has proved disappointing. While renal disease may generally be 
detected with ease, it is still impossible to say in any given case if 
sufficient renal tissue is present to permit the vital processes to go 
on. Cryoscopy, it is true, has proven of enormous value to the 
surgeon, and, by contraindicating operation, has saved many a 



PATHOLOGY AND PHYSIOLOGY OF THE KIDNEYS. 23 

patient from a quick death by uremia. But later researches have 
shown that this method, though simple and practical, is far from 
accurate (see Chapter XI). 

It may not he amiss to touch briefly upon the lesions which com- 
monly affect the kidneys, and their relation to the composition of 
the urine. Every degenerative or inflammatory process affects 
most seriously the most highly differentiated element of the kidney 

Fig. 7. 

M ■-'>? m, 

' , s - ■,." * - i >" - - w 



mi 







■ * l s <^ « 



^ :* *v- 



^W- 












'•"5 



Fatty degeneration of the kidney. The fat stained black with osmic acid. X 50. (Schmaus.) 

— the renal secreting cell. The protoplasm of the cell and its 
nucleus will break down and pass into the urine. By far the 
greater portion of the albumin, however, is serum albumin and 
serum globulin, derived directly from the blood, since the pores of 
the filtering apparatus have become coarser and the secreting func- 
tion is seriously interfered with. Since the glomerular endothe- 
lium is the most delicate of all the elements, the tubular cells will 
be affected later, and only in the more severe disturbances. It 



24 



EXAMINATION OF URINE. 



is still doubtful whether tubular degeneration alone will permit an 

excretion of albumiu, for in cantharides poisoning, where the 

changes are most marked in the lining cells of the convoluted 

tubules, albuminuria is often absent. 

Other phenomena of nephritis which are responsible for the 

characteristic changes of the urine are the circulatory disturbances 

which occur in the acute forms, as congestion ; in the chronic types, 

as cardiac hypertrophy, arteriosclerosis and variations in vascular 

tension. A slowing of the blood-stream will bring less nutrition to 

the cells, disturb their metabolism, and thus make them more 

permeable for albumin. 

Fig. 8. 




W mm, 



Parenchymatous hemorrhagic nephritis with desquamation in the glomeruli. In the 
capsule of Bowman lie many desquamated epithelia. In many tubules there are masses of 
red cells. Above to the left a focus of round-cell infiltration in the stroma. Fibrous increase 
about the glomerulus. X 2o0. (Schmaus.) 

Vascular disturbances will also bring about changes in color, 
amount and concentration, which are more or less characteristic 
for the different forms of nephritis. The amount of water ex- 
creted will rise if the amount of blood which circulates through the 
kidneys is increased; that is, if the arterial pressure rises without 
change in the lumen of the vessels, and without increased resist- 
ance, or when the pressure remains normal, but the vessels dilate. 
The former condition is often seen in chronic interstitial nephritis, 
for arterial tension and cardiac hypertrophy almost invariably 
accompany this condition. If digitalis be given to patients with 



PATHOLOGY AND PHYSIOLOGY OF THE KIDNEYS. 25 

cardiac disease, arterial pressure will rise and increased diuresis 
will follow. 

The second condition, normal pressure, with dilated vessels as a 
cause for an increased secretion of urine, is seen after dividing the 
renal nerves, and may be the cause of polyuria in insipid diabetes. 

Less blood carried to the kidneys will mean less secretion of 

Fig. 9. 




Amyloid degeneration in the kidney, a, b. glomerular vessels, still permeable ; 0.0,0^ 
amyloid vessels; at c t the lumen can still be traced; d, amyloid capillaries of the stroma 
/, tubule; <?, artery. X 40. <Schmaus.) 



urine. This is common when the renal vessels are also involved in 
the general increase of arterial tension, or when they retain their 
normal width, but the arterial pressure is lowered or the venous 
pressure increased, so that the blood-flow within the kidney is 
retarded. The general increase in tension is best seen in asphyxia, 
strychnine poisoning, epileptic and eclamptic convulsions, the 
retardation of blood-How in thrombosis or cardiac weakness. 
Retardation is also one of the phenomena of inflammation, and it is 



26 



EXAMINATION OF URINE. 



but logical that an inflamed kidney should excrete subnormal 
amounts of urine. 

Another cause for diminished excretion is probably to be found 
in the occlusion of the tubules by detritus from the renal cells, 
casts, etc. We cannot say, however, if this deposit is caused by 
the diminished pressure or whether it really forms an impediment 
to the free flow of urine Obstructions lower down, such as stenosis 
of the ureter, will naturally diminish the speed of excretion. 

■ ' Fig. 10. 




Chronic interstitial nephritis, b, ft 1 , areas of atrophy and induration ; /t 1 , atrophic tubule; 
g, glomeruli still persisting; g 1 , destroyed; 6 1 , round-cell infiltration; e, depression of the 
surface ; gr, granules where the tubules are less affected ; h, wider tubule; h", cystic tubule ; 
<//, thickened vessels. X 30. (Sehmaus.) 



It is an interesting fact that but one kidney is necessary for life, 
provided sufficient time elapses to permit the organ to increase in 
size and approximately perform the functions of two. While 
acute and chronic nephritis, as a rule, are bilateral, surgical affec- 
tions, such as abscess and tuberculosis, frequently affect only one 
organ. In the more chronic processes sufficient opportunity is 
given to the remaining healthy organ to hypertrophy, so that life 
need not be seriously menaced by a nephrectomy. 

The intimate relation of proper renal function to the well-being 



PATHOLOGY AXD PHYSIOLOGY OF THE KIDNEYS. 



27 



of the entire body is clearly seen in the later stages of chronic- 
nephritis. The constant loss of albumin is hardly sufficiently large 



Fig. 11. 



Jfe^. 










: " i 



m 



^m 



m 



■r 






Glomerulus in degeneration. Thick hyaline capsule tightly applied to the tuft, its cavity 
lost, some vascular coils hyaline (darker); externally loose connective tissue. X 350. 
(Schmaus.) 

to lead to a cachexia, but where much renal tissue has been 
destroyed by a parenchymatous or interstitial process, a retention of 

Fig. 12. 







Growth of connective tissue into the capsule of Bowman from the hilum. the original 
limits as a darker line. X 350. (Schmaus.) 



excrementitious products occurs, which gradually or suddenly will 
lead to the intoxication known as uremia. Strangely enough, our 



28 EXAMINATION OF UBIXE. 

knowledge concerning the principles which are directly responsible 
for this condition are singularly incomplete, and this is hardly the 
place to enumerate the various theories which have been advanced 
at one time or other. We seem to be just as far to-day from a 
plausible explanation of the peculiar nervous and cardiovascular 
symptoms which mark uremic intoxication as we were fifty years 
ago. 

In examining a urine, it must not be forgotten that the excretion 
passes through the ureters and is stored in the bladder some time 
before it is voided, and that in both places it may undergo con- 
siderable change. To determine whether a variation from the 
normal will point to a renal or vesical lesion may at times be a 
difficult task for the physician, but, fortunately, ureteral catheteri- 
zation will now enable him to examine the urine from each kidney 
directlv. 



CHAPTER II. 

PHYSICAL PROPERTIES OF URINE. 

Amount. — Normally the amount of urine varies within very 
wide limits, the figures generally given being 1,000-2,000 c.e. for 
twenty-four hours. Age and sex have but a moderate influence, 
but the effect of ingested fluid, external temperature and exercise 
is very marked. 

During hot weather the excretion of water by the skin is more 
active, and the figures frequently are low, even though more water 
is taken. Generally speaking, the secretion of urine varies con- 
siderably during different parts of the day, it being greatest several 
hours after a meal and least during the first hours of the night. 

In morbid conditions the urine may be entirely suppressed, or it 
may be diminished or increased. Suppression of urine must be 
carefully distinguished from retention of urine, in which there is 
some obstruction to the flow in the genito-urinary tract, beyond the 
secreting apparatus. Diminished flow is generally known as 
oliguria, increased flow as polyuria. 

Complete suppression (anuria), if not a hysterical symptom, is 
generally an accompaniment of uremia, and frequently precedes 
death. In cases without distinct renal history, retention should 
be ruled out by catheterization. Rarely the obstruction may be 
higher than the bladder, as in stone obstructing the ureters, or in 
accidental ligation of both ttreters. It is even possible for a 
normal kidney to cease secreting, owing to reflex nervous influences, 
if the opposite ureter is obstructed (reflex anuria), though this 
occurrence has been doubted and is not as frequent as Avas formerly 
believed. 

A diminished amount of urine is a common symptom in conges- 
tion of the kidneys, such as accompanies cardiac disease, with loss 
of compensation and many febrile disorders, since heart action 
and blood-pressure are generally lowered and less blood flows 
through the renal vessels. 

Oliguria is also a prominent symptom of acute nephritis and 
chronic parenchymatous nephritis, owing to the degeneration of the 
renal cells and the mechanical resistance offered by the exudate. 
Less common causes for diminished urinary flow are pressure upon 

(29) 



30 EXAMINATION OF URINE. 

the vena cava, owing to tumor or excessive ascites, thrombosis of 
the inferior vena cava or the renal vein, hepatic disease accom- 
panied by obstruction to the flow of blood in the liver, cholera, 
severe hemorrhage and various nervous conditions. 

Polyuria is common to two diseases — diabetes mellitus and 
chronic interstitial nephritis — but in either case a clear explanation 
of this symptom does not exist. Many organic and functional 
nervous diseases (hysteria, diabetes insipidus, epilepsy, tabes, etc.) 
are characterized by an excessive flow of urine, and active diuresis 
is often seen during the absorption of exudates in convalescence 
from prolonged fevers (epicritic polyuria) and with multiple 
myelomata of the bones. The most excessive degrees of polyuria 
have been observed in diabetes mellitus and insipidus (up- to 
43,000 c.c). 

Appearance.— Xormal urine, when freshly voided, forms a 
clear, transparent, amber-colored fluid. In summer, alkaline salts, 
or organic salts which readily become alkaline in the body, are 
frequently ingested in large amounts with fruit, etc., so that the 
urine, though fresh, may be turbid, owing to the precipitation of 
phosphates. Similarly, in winter uric acid and urates may pre- 
cipitate out in the form of a brick-dust sediment or a diffuse milky 
turbidity if the urine is kept in a cold place. The phosphates are 
redissolved by slightly acidifying with acetic acid, the urates by 
gently warming. In most urines a distinct cloud (nubecula) will 
slowly settle to the bottom if allowed to stand for several hours. 
This cloud consists of mucus in which are entangled desquamated 
epithelial cells. In warm weather a diffuse turbidity will form, 
owing to the proliferation of bacteria. This should be avoided, 
since such urines are difficult to filter and the more delicate mor- 
phological elements are often destroyed. Pathological turbidity 
may be due to pus cells or bacteria from the kidney itself, its pelves, 
bladder or urethra. In women a certain amount of turbidity is 
often due to admixture with menstrual blood or vaginal discharge. 

Normal urine varies in color from a pale yellow to a dark amber, 
depending upon its degree of dilution. Very pale urines generally 
go with polyuria, and are therefore common in chronic interstitial 
nephritis, diabetes and hysteria. Dark urines indicate concentra- 
tion, and are met with in acute and chronic parenchymatous neph- 
ritis, in the congestion of heart disease and in fevers. Oftentimes 
the urine lacks its characteristic yellow or amber hue, and is dif- 
ferently colored. 

If orange, urobilin may be present; if greenish-yellow or 



PHYSICAL PROPERTIES OE URIXE 



ol 



greenish-brown, with yellow foam, bile ; if red or reddish-black, 
blood; if green, phenol, creosote or guajacol; if blue, methylene 
blue ; if pink, pyramidon ; if red, hematoporphyrin, santonin, the 
principles of rhubarb, etc. ; and if milky, fat in emulsion. In the 
presence of alkapton, melanin or phenol the urine may be dark 
when voided or change color soon after. 



Fig. 13. 




"Crhiometev. (W. Simon.) 

Odor. — Owing to the presence of volatile acids, urine has a dis- 
tinct, characteristic odor. Alkaline, decomposed urine is ammo- 
niacal, while the ingestion of oil of turpentine, asparagus, etc., also 
modifies the smell. 

Specific Gravity. — The determination of the specific gravity 
of urine gives an idea of the total amount of solid substances. 
Since the most abundant of these are urea and sodium chloride, the 



32 j:\amj\atjo\ of i iuxe. 

concentration of any given nrine depends in greater part upon 
these. The normal figures vary between 1,005 and 1,030, usually 
1,015-1,025. 

Since variations occur from hour to hour, it is more accurate to 
employ the mixture obtained during twenty-four hours. A sam- 
ple of this is poured into a cylindrical glass, care being taken to 
avoid foaming. The usual urine-meter is an ordinary hydrometer 
accurately graduated between 1,000-1,050. It is simply dipped 
into the fluid in the cylinder, and the reading taken at the level 
where it floats. AVhile this method is simple and accurate, con- 
siderable difficulty may be experienced where the quantity of urine 
at hand is so small that it docs not fill the cylinder. Sufficiently 
accurate results can then be obtained by diluting once with water 
and multiplying the last two figures of the result by 2. With still 
smaller quantities the following methods are at our disposal: 
1. Jolle's hydrometer, requiring 20-25 e.c. to float. 2. Mohr- 
Westphal balance, requiring about 15 c.c. This instrument is 
most accurate, but too expensive for ordinary work. 3. Pvk- 
nometers. These require a good deal of skill and a very expensive 
balance. 1. The use of a mixture of two fluids of different specific 
gravity, such as are employed for blood-work. 5. The Urino- 
pyknonioter of Saxe. This instrument is very easy to handle, 
requires only a small amount of urine and is very cheap in price. 
It is shaped like an ordinary hydrometer, but is provided with a 
cup above the stem, into which 5 c.c. of urine are placed. By then 
floating in distilled water, at 15 c.c, an accurate reading is possible. 

An approximate idea of the total solids contained in urine may 
be obtained by multiplying the last two figures of the specific 
gravity by 2. Thus, if the specific gravity of the voided urine is 
1,015, there will be about 30 grams of solid matter to the litre. 
According to llaeser, more accurate results will be obtained by 
multiplying by 2.33. 

A low specific gravity is obtained after the use of much water or 
the administration of diuretics in chronic interstitial nephritis, 
diabetes insipidus and other nervous forms of polyuria. As a 
rule, low specific gravity accompanies an abundant excretion and a 
high specific gravity a scant amount of urine, but a diminished 
amount with high specific gravity is common in many chronic dis- 
eases, and toward the fatal termination of acute disease, in some 
cases of edema and after copious vomiting, diarrhea and sweating. 
In diabetes mellitus there is generally polyuria with high figures, 
owing to the presence of varying amounts of glucose. 



PHYSICAL PROPERTIES OF L'Rl^E. IS 

Reaction. — Urine when voided is most usually acid, but may 
als<> be amphoteric or alkaline, without indicating lesion. Blue 
and red litmus paper are generally employed to indicate the 
reaction. The acidity is caused not by uric acid, but by disodium 
acid phosphate, XaII 2 S0 4 ; alkalinity by an excess of carbonates 
and of neutral sodium phosphate and an amphoteric reaction by 
the presence of certain proportions of both acid and neutral phos- 
phate. Highly concentrated urine is often very acid, while the 
ingestion of food rich in organic salts, which are burned up into 
alkaline carbonates, will increase the alkalinity of the blood and 
more than neutralize the acid salts in the urine. The free excretion 
of gastric juice after a large meal will also tend to change the 
reaction. Even in disease the urine is acid in the majority of cases, 
unless there is inflammation, or stagnation in the bladder. The 
same changes that occur when urine is allowed to stand exposed to 
the air are then apt to follow: the urea is simply converted into 
ammonium carbonate, owing to micro-organismal activity. 

In order to determine the degree of acidity, Freund has 
recently devised the following method, which is rather complicated 
for ordinary nse : 

The total amount of phosphoric acid is determined in 50 c.c. of 
urine, according to the usual method. Ten c.c. of a 12.2 per cent, 
solution of barium chloride for every 100 milligrams of phosphoric 
acid present are then added to another 50 c.c. to precipitate the 
monacid phosphates. After the addition of the barium, the 
mixture is diluted up to 100 c.c, filtered and the phosphoric acid 
estimated in 50 c.c. of the filtrate. Supposing that the total 
amount of phosphoric acid amounted to A and the last phosphoric 
acid determination to B, the relative proportion of A to B would 
be determined according to the equation 

100 B 
A :B : : 100 :X X = 



The total acidity for twenty-four hours is then calculated by multi- 
plying X by the number of 100 c.c. voided and the total acidity per 
hour by dividing this number by 21. 

If the urine is alkaline and cloudy, the sediment is dissolved by 
shaking with one-tenth normal hydrochloric acid and deducting the 
amount from the total acidity. 

The above method of determining the total acidity is not fre- 
quently employed. Titration with decinormal sodium hydrate 



34 



EXAMINATION OF URINE. 



solution, using phenol-phthalein as indicator, is inaccurate, but will 
often suffice for comparative figures. The depth of the red 
obtained on using blue litmus will do, however, for clinical work. 

Molecular Concentration and Osmotic Pressure. — Cryoscopy, or 
the determination of the freezng-point of the urine, is a new 
department of urinalysis which is coming more and more into 
favor, and which gives valuable information concerning the func- 
tional activity of the kidneys, though not as infallible as first 
believed. It is based upon the observations of Eaoult (a) that all 



Fig. 14. 




m,a- 



Beckmann's apparatus. (Simon. 



solid, liquid or gaseous substances, when dissolved in a liquid, will 
lower the freezing-point of that liquid; (b) that the degree to 
which the freezing-point is lowered depends upon the amount of 
substance which is in solution, and (c) that equimolecular solu- 
tions have like freezing-points. Distilled water freezes at 0° C, 
urine in health at — 0.9° C. to — 2° C. This figure is generally 
designated by the capital Greek letter A, while the corresponding 
small letter 8 signifies the freezing-point of blood-serum, which is 
normally — 0.56° to — -0.58° C. Since more constant, the latter 
is generally preferred, though very valuable information may be 



PHYSICAL PROPERTIES OE URINE. 35 

obtained by ureteral catheterization and separate determination of 
both urines. 

A freezing-point above — 0.9° C. indicates low molecular con- 
centration, and shows better than the amount of urea or the specific 
gravity that the function of that particular kidney is seriously 
interfered with, perhaps to such an extent that operation is 
eontraindicated. A comparative high congealing point of the 
urine goes hand in hand with a depression of the freezing-point of 
the serum, since this will possess higher molecular concentration, 
owing to the presence of retained excrementitious products. 

Cryoscopy is practiced by means of a very simple apparatus, 
whose component parts are a delicate thermometer graduated in 
hundredths of a degree, a test tube for the urine or serum, Avhich 
is provided with a stopper perf orated for the thermometer, and a 
platinum stirring-rod, and finally a large glass jar, which is filled 
with ice and salt and also contains a stirring-rod. If the ther- 
mometer be watched as the test-tube is placed into the freezing 
mixture, the column of mercury will gradually fall, then suddenly 
rise and reach a stationary point, which corresponds to the con- 
geal ing-point of the fluid examined. In every case distilled water 
should be employed first. The difference between the freezing- 
point of this and of the urine will then indicate the number of 
degrees below zero. It is necessary to keep the fluid in constant 
motion bv agitating with the stirring-rod. 



CHAPTER III. 

CHEMISTRY OF URINE. 

There are certain reactions which all urines have in common. 
Briefly, they are the following: 

1. Acids on wanning will darken the urine and cause a pre- 
cipitation of uric acid crystals when cooled. 

2. Caustic alkalies cause turbidity and precipitation of earthy 
phosphates. 

3. Lead acetate throws down a white precipitate, consisting of 
chloride, phosphate and sulphate of lead, together with pigments, 
so that on filtering the urine may be almost colorless. A slightly 
colored urine is especially desirable where a large column of urine 
is examined by light, as in polariscopy. 

4. Silver nitrate gives rise to a white precipitate of chloride 
and phosphate of silver. 

5. Barium chloride throws down the phosphates and sulphates. 

6. Ferric chloride in the presence of sodium acetate precipi- 
tates the phosphates. 

7. Alcohol gives a turbidity, which disappears on diluting with 
water. 

8. Boiling will have no effect unless the urine is amphoteric or 
alkaline, when the earthy phosphates will precipitate. 

Urine is always a complex fluid, which contains many substances 
in solution. These may be divided into organic and inorganic. 

ORGANIC IXGREDIENTS. 

Urea 30 grammes in twenty-four hours 

Uric Acid 0.7 " " " " 

Kreatinin 1.0 " u " " 

Hippuric Acid 0.7 " " " " 

Other bodies 2.6 " " " " 

Xanthin bodies, oxalic and oxaluric acids, volatile fatty acids, 
lactic and succinic acids, carbohydrates, glycerino-phosphoric acid, 
salts of phenyl- p-cresyl-, pyrocatechin-, indoxyl- and skatoxyl- 
sulphuric acids, phenol, p-oxyphenylic and p4rydrocumarinic acids, 
glycuronic acid, pigments, ferments and other substances of un- 
known composition. 

(36.) 



CHEMISTRY OF URINE. Si 

IXOKGANIC INGREDIENTS. 

Hydrochloric Acid 0.35 grammes in twenty-four hours 

Sulphuric Acid 2.5 " " " " 

Phosphoric Acid 2.5 " " " " 

Nitric Acid . . '. 0.1 " " " 

COMBINED WITH 

Sodium (Na 2 0) 7.9 grammes in twenty-four hours 

Potassium (K 2 0) . 3.0 " " '" " 

Ammonium (NH H ) 0.7 " " " " 

Calcium (CaO) 0.3 " 

Magnesium (MgO) 0.5 " " " " 

Iron, trace 

GASES. 

Oxygen 1.0 c.c. 

Carbon Dioxide -. 24.0 " 

Nitrogen 10.16 " 

Urea. ( [ 2sH 2 ] 2 CO). — In health, and generally in disease, the 
amount of urea in the urine is a good index of the total nitrogenous 
excretion, since it usually forms about 85 per cent, of all nitrogen- 
ous bodies. There is no doubt that urea represents the proteid 
tissue waste, but as yet there is considerable speculation upon the 
intermediate principles: According to the most popular theory, 
the waste nitrogen leaves the tissues as the ammonium salt of 
paralactic acid. This is then changed into ammonium carbonate 
by the liver, and finally into urea through the intermediary forma- 
tion of ammonium carbamate. 

Urea is derived in part from the organized albumin, in part 
from the reserve albumin circulating in the blood. A clear idea 
of the tissue waste going on within the body can generally be 
obtained by a quantitative estimation, yet in some diseases the 
proportion between urea and other nitrogenous principles is so 
disturbed that a total nitrogen determination will become neces- 
sary. This applies especially to acute yellow atrophy of the liver, 
where the urea may disappear from the urine, and to the leukemias 
and gout, where uric acid is often in excess. 

Since every urine contains some urea, a qualitative analysis will 
hardly ever be necessary, unless one wishes to decide if a certain 
fluid is urine. The quantitative analysis is, however, of the greatest 
importance, since, like cryoscopy, it gives a good idea of the 
functional activity of the kidneys. The normal amounts vary be- 
tween 10 and 20 grammes per litre, and bear a direct relation to the 



38 EXAMINATION OF URINE. 

specific gravity; thus concentrated urines contain much, dilute 
urines little of this substance. In disease the amount is increased 
when metabolism is more active, as in fevers. This is especially 
marked in fevers terminating by crisis. Excessive excretion may 
also occur in diabetes mellitus, in part due to the increased con- 
sumption of proteids, in conditions associated with dyspnea, in 
pernicious anemia, leukemia, scurvy and certain nervous affections, 
and after the use of caffeine, chlorides, carbonates and some of the 
alkalies. 

Diminished elimination of urea is most pronounced in serious 
hepatic disturbance, such as acute yellow atrophy, cirrhosis and 
carcinoma, because urea is no longer formed, and in renal disease 
because it can no longer be excreted. Since the convoluted tubules 
are chiefly concerned with the excretion of urea, a nephritis involv- 
ing chiefly the glomeruli need not be accompanied by retention of 
nitrogenous matter. There is also a deficiency of urea in some 
nervous and mental disorders. 

Uric Acid. — Though the main nitrogenous principle in the 
urine of birds and reptiles, uric acid plays but a subordinate role 
in mammals and man, as compared with urea. It is, in all proba- 
bility, derived from the nuclear substance of cells, through bases 
spoken of collectively as xanthin, purin or alloxur bodies (adenin, 
guanin, sarcin or hypoxanthin), which are closely allied chemic- 
ally to caffeine or theobromine. All the organs elaborate the acid, 
but nuclear organs, such as the spleen or lymph-nodes, yield more 
than muscle-tissue. 

The daily amount of uric acid excreted is usually very small 
(0.2-1.5 gme.), and thus forms only a small part of the total 
nitrogen. Animal food generally causes a considerable increase, 
but the relation which the elimination of uric acid bears to disease 
is still imperfectly understood. 

In gout a diminution is generally noted before the attack, and 
an increase directly after; but abnormal figures are found in so 
many normal conditions that only the continuous increase would 
speak for a gouty diathesis. An excessive amount is more con- 
stant in the various leukemias, owing to the active disintegration of 
leucocytes, and in some febrile diseases terminating by crisis, while 
a diminution sometimes occurs in diabetes and anemia. 

Kreatinin. — Kreatinin is derived from kreatin, a substance 
found in muscle, and is excreted in amounts of about 1 gramme 
daily. More than this would signify an increased breaking down 
of muscle-tissue, provided the patient is not upon a strict meat diet. 



CHEMISTRY OF URINE. 39 

Since the change of kreatin into kreatinin occurs in the 
kidneys, a diminution of the latter substance is to be looked for in 
advanced chronic parenchymatous nephritis. Other conditions 
sometimes accompanied by a diminution are anemia, phthisis and 
the muscular atrophies. Chemically, kreatinin is closely allied 
to guanidin and giycocoll. 

Hippuric Acid. — Salts of hippuric acid are constantly present 
in normal urine, though only in very small quantities (0.1-1.0 
gramme daily). Chemically, hippuric acid is benzqyl-amido-acetic 
acid; it is the only known amido-acid voided normally with the 
urine. Its nitrogen corresponds to 2.89 per cent, of the total 
nitrogen, according to Landau. It is now generally assumed 

Fig. 15. 




Hippuric acid crystals. (Simon.) 



that hippuric acid results from the synthesis in the kidneys of 
benzoic acid and giycocoll, both of which are derived from products 
of intestinal putrefaction. An excess may be expected after the 
ingestion of fruits rich in benzoic acid and in acute fevers, diseases 
of the liver and diabetes mellitus ; a. diminution in chronic paren- 
chymatous nephritis and amyloid degeneration of the kidneys. 

Xanthin (Purin or Alloxur) Bodies. — The chief representatives, 
of these are xanthin, heteroxanthin, paroxanthin, guanin and 
adenin. Xanthin is the only one which occurs in appreciable 
quantities, and it is, furthermore, of importance in that it rarely 
may be the principal constituent of renal stones. Collectively, the 
purin bodies amount to about 10 per cent, of the uric acid present, 
and their nitrogen forms 1 per cent, of the total nitrogen. Since 



40 EXAMINATION OF URINE. 

mother substances of uric acid, they are generally increased and 
diminished under the same conditions as this. 

Oxalic and Oxaluric Acids. — The origin of oxalic and oxaluric 
acids is still in dispute. According to some, they are derived 
from the uric acid by a process of oxidation; according to 
others, the connective tissue of the ingested food forms the main 
source. 

There are a large number of vegetables (carrots, tomatoes, 
spinach, rhubarb, figs, plums, coffee and strawberries ) which con- 
tain a considerable percentage of the acid, and under certain 
conditions it may be formed from ingested carbohydrates. The 
normal daily amount is usually below 0.01 gramme, but in some 
cases of neurasthenia associated with hyperchlorhydria this amount 
is considerably increased (oxalic acid diathesis), for unknown 
reasons. Variations have also been described in a number of other 
diseases, but these are unimportant, since not constant. 

Ferments. — Passing mention may be made of the fact that 
every normal urine contains traces of a ferment, which is nothing 
but. pepsin secreted by the stomach and excreted by the kidneys. 

Pigments. — Every normal urine contains some pigments which 
impart to it the yellow color. The most important of these are 
urochrome, also called normal urobilin, and uroerythrin. The 
former is indirectly derived from the blood, hence is increased in 
amount when an absorption of a large amount of blood is taking 
place and diminished when there is a new formation of red cor- 
puscles. Uroerythrin is the pigment which colors uric acid crys- 
tals and uratic deposits. It is closely related to hemoglobin, and 
is said to be increased in hepatic disease. 

There are also present in normal urines certain bodies which, 
though colorless, are readily converted into pigments, and are 
hence called chromogens. The most important of these is indican, 
the sodium or potassium indoxyl sulphate, obtained by the union 
of the indol of intestinal putrefaction with sulphuric acid, and the 
corresponding skatoxyl salts, formally, only faint traces are 
excreted (about 6-7 milligrams in a litre of urine), but in the fol- 
lowing conditions there is a decided increase : Auchlorhydria and 
hypochlorhydria, especially in carcinoma of the stomach; occa- 
sionally in the hypersecretion associated with ulcer ; in obstruction 
involving the small intestines, and wherever proteid decomposition 
is going on in the body, as in empyema, putrid bronchitis and 
gangrene of the lung. 

The tests for indican depend upon its oxidation to indigo-blue. 



CHEMISTRY OF URINE. 11 

Phenol. — Found in traces in health, and in larger quantities 
whenever a decomposition of proteids is going on in the body and 
after the ingestion of phenol (carbolic acid) or its derivatives. 
Its significance is, in the main, the same as that of indican. and 
skatol. Differential diagnosis may be assisted by the fact that 
phenol is often absent in typhoid fever, but present in tuberculous 
meningitis. 

Other Organic Bodies. — About 10 per cent, of the sulphur 
excreted (neutral sulphur) is found in certain organic compounds, 
chief among which are the sulphocyanides, derived ft om the saliva 
swallowed, and the closely allied cystein. Possibly tauro-carba- 
minic acid is also a normal constituent of human urine. 

The property of almost every normal urine to turn the ray of 
polarized light to the left is due to the presence of small amounts 
of combined glucuronic acid (see next chapter). 

Chlorides. — Xext to urea, the substance occurring most abun- 
dantly in urine is chloride of sodium (about 15 grammes daily). 
The chlorine, combined with potassium, ammonium, calcium and 
magnesium, is much smaller in amount, and it is customary to 
express the total chlorine in terms of sodium. It is almost entirely 
derived from the food, since more is ingested than is required by 
the body. 

A marked diminution of chlorides is common to febrile disorders 
and acute and chronic renal disease. It was formerly considered 
pathognomonic for lobar pneumonia, but closer investigation . 
showed that the urine of all other conditions associated with 
marked rise of temperature, with the possible exception of malaria, 
is poor in salt. A decrease is also observed in various gastric dis- 
orders (cancer, dilatation, ulcer), anemia and some mental dis- 
eases. An increase may be associated with all conditions in which 
retention has previously occurred, and during the resorption of 
exudates and transudates. From a prognostic point of view, a 
very marked diminution of chlorides during fevers (0.05 gme. 
daily) points to extreme gravity, while an increase from day to 
day speaks for an improvement. An idea of the digestive func- 
tions of the patient may also be obtained, it being the rule that with 
10-15 grammes daily the digestive power is normal. 

Sulphates. — Sulphates in the urine are derived chiefly from 
the decomposition of the proteid material of the body, and only to 
a slight extent from the sulphates actually ingested. They occur 
either as mineral sulphates (preformed sulphates) or in combina- 
tion with certain organic radicals derived from intestinal decom- 



42 EXAMINATION OF URINE. 

position, chief among which are phenol, indoxyl and skatoxyl 
(conjugate or ethereal sulphates). The normal amount for the 
total sulphates in twenty-four hours is about 2 or 3 grammes, while 
the relation of preformed to conjugate sulphates is as 10 to 1. It 
is thus natural that an excessive amount of sulphates is excreted 
wherever tissue metabolism is stimulated, as in acute fevers or 
where there is much intestinal putrefaction, as in coprostasis. The 
determination of the conjugate sulphates does not, however, offer 
as valuable an index as that of indican, since only the aromatic 
part of the proteid molecule is concerned in their excretion. An 
increase has also been noted in a number of other diseases, such as 
leukemia, diabetes and progressive muscular atrophy, while the 
conjugate sulphates alone may be abundant in diminished secre- 
tion of gastric juice and in obstructive jaundice. Subnormal 
figures are commonly seen with chronic renal disease and during 
convalescence from fevers. 

Phosphates. — Since phosphoric acid occurs in the urine in 
combination with potassium, sodium, calcium and magnesium, and 
the acid itself is tribasic, twelve different combinations are possi- 
ble. In addition, a small amount is usually found combined with 
glycerine, as glycerino-phosphoric acid. The most important salt 
is the diacicl sodium phosphate (NaTI 2 P0 4 ), to which the acidity 
of the urine is clue ; but in case the urine voided is amphoteric or 
alkaline in reaction, the more basic compounds are in excess. 
The normal amount of phosphoric acid excreted is about 2.5 
grammes. Its source is the food ingested, and to a less degree the 
disintegrated proteid molecule of the tissues. A diminished excre- 
tion is noted in acute fevers, kidney and bone disease ; an increased 
elimination in the so-called phosphatic diabetes and during con- 
valescence from acute fevers. 

i titrates, carbonates and iron salts occur in the urine in mere 
traces, and their excretion bears no definite relation to any dis- 
ease. They are chiefly derived from food ingested, the nitrates 
and carbonates, or salts readily breaking up into carbonates, being 
abundant in vegetables and fruits, and iron in vegetables and 
muscle tissue. The estimation of sodium, potassium, calcium and 
magnesium is of little value. Ammonia normally * constitutes 
about 4.1-4.7 per cent, of the total nitrogen present; that is, it is 
excreted to the extent of about 0.7 gramme daily. It is present 
in combination with various acids, and suffers an increase with 
extensive parenchymatous degeneration, such as acute yellow 
atrophy : arid phosphorus poisoning, in respiratory dyspnea and 
diabetes mellitus. 



CHAPTEK IV. 

THE ABNORMAL CONSTITUENTS OF THE URINE AND THEIR 
SIGNIFICANCE. 

The following substances may occur in the urine during disease : 



Albumin 



Sugar 



Serum albumin. 

Serum globulin 

Albumose. 

Peptone. 

Bence- Jones albumin. 

Fibrin. 

Nucleoalbumin. 

Mucin. 

Histon. 

Nucleoliiston. 
r Glucose. 

Lactose. 

Maltose. 

Levulose. 

Laiose. 

Pentose. 
I Glycuronic Acid. 



Acetone. 
Diacetic Acid. 
/3-Oxy butyric acid. 



Hemoglobin. 

Melanin. 

Bile-pigments. 

Bile acids. 

Urobilin. 

Fats. 

Cholestrin. 

Leucin. 

Ty rosin. 

Cystin. 

Alkapton 

Chromogens respon- 
sible for the diazo 
and dimethylami- 
dobenzal d e h y d e 
reaction. 

Lactic acid. 

Oxyamygdalic acid. 

Volatile acids. 

Ptomaines. 

Hydrogen sulphide. 

Drugs. 



Albumin. — Though minute traces of albumin may be found in 
every normal urine if large quantities are examined by special 
chemical methods, the detection of even traces by the ordinary 
reagents is probably always pathological. An exception must, 
however, be made in case of female urines spontaneously voided. 
These almost always contain minute quantities, owing to admixture 
with, vaginal secretion. 

The most common and important albumin occurring in urine is 
serum albumin. This is soluble in water, dilute solutions of salt 
and concentrated solutions of sodium chloride and magnesium sul- 
phate, but is precipitated by ammonium sulphate and by heating 
up to 72-75° C. Concentrated acids change it into acid albumin, 
which is soluble in acetic acid, while alkalies convert it into alkali 
albumin. 



(43) 



44 EXAMINATION OF URINE. 

Serum globulin is insoluble in water and concentrated solutions 
of chloride of sodium, sulphate of magnesium and sulphate of 
ammonium. It is coagulated at about the same temperature as 
serum albumin. 

The presence of serum albumin and serum globulin in the urine 
is termed albuminuria. This albuminuria may be renal where the 
abnormal condition depends upon some lesion in the kidney cells, 
or accidental where there is an admixture of albuminous exudate, 
blood or lymph from the lower genito-urinary tract. Renal 
albuminuria, as a rule, signifies that the cells of the glomeruli and 
the convoluted tubules are so altered that they permit the albumin 
of the blood to pass through. Hence we find appreciable quanti- 
ties of albumin in all forms of acute and chronic degeneration, 
congestion and inflammation of the kidneys. An exception is only 
seen in certain forms of chronic interstitial nephritis, where the 
low specific gravity and the presence of various forms of casts alone 
point to a pathological renal condition. There is, however, another 
form of renal albuminuria, often wrongly termed physiological 
albuminuria, which is often noticed in young individuals at certain 
times of the day or at certain regular periods. While its pathology 
and significance are not as yet clearly understood, it must be looked 
upon as a decidedly abnormal condition. At times it is brought 
on by a cold bath or severe muscular exertion ; sometimes it dis- 
appears with rest in bed, to make its reappearance as soon as the 
patient is up and about (orthostatic albuminuria). Casts are 
frequently absent, and the subjective symptoms beyond those of 
a concomitant anemia are slight. Recently, however, it has been 
shown that there are often slight cardiac changes. 

Accidental albuminuria is generally due to the addition of 
albuminous material, such as blood, lymph or semen in the bladder 
or urethra. Blood, pus, etc., may also come from the kidney or 
renal pelvis when the term accidental renal albuminuria is used. 

While the term "albumin in the urine" generally signifies both 
serum albumin and serum globulin, appreciable quantities of the 
latter are only noticed in amyloid degeneration. 

Albumoses are intermediary products, formed by the conversion 
of albumin into peptone by ferments. Three varieties are recog- 
nized : protalbumoses, soluble in water and precipitated by saturat- 
ing with chloride of sodium or sulphate of magnesium; hetero- 
albumoses, insoluble in water, soluble in physiological salt solution 
and precipitated at 65° C, and deuteroalbumoses, soluble in water 
and precipitated only by saturating with ammonium sulphate. 



ABNORMAL CONSTITUENTS OF THE URINE. 45 

Albumosuria is observed wherever there is a large accumulation of 
pus in the body, and in some diseases of the liver and intestinal 
tract. Its detection may be of value in distinguishing between 
epidemic and cerebrospinal meningitis. 

Most text-books state that peptone, in the modern sense of the 
word, does not occur in urine. Recently, however, Ito 1 has demon- 
strated its presence in pneumonia, advanced phthisis, ulcer of the 
stomach and after child-birth. 

Over fifty years ago Bence Jones described a peculiar albumin 
in the urine of cases suffering from multiple myelomata and other 
tumors of the bones. The recent researches of Magnus-Levy and 
Simon make it probable, however, that the substance is a true 
albumin, which differs from other members of the group in that it 
dissolves in dilute ammonia after precipitation with alcohol. This 
substance should be looked for in .all cases of obscure anemia, 
especially where pain in the bones is complained of. Its presence 
does not, however, seem to be absolutely constant 2 , for several 
cases have been reported where the clinical symptoms and autopsy 
findings were those of myeloma, yet Bence Jones bodies were 
absent. 

Fibrin occurs but rarely, and is generally associated with 
chyluria or diphtheritic inflammation of the genito-urinary tract. 
Jt has also been encountered in hydronephrosis and chronic inter- 
stitial nephritis 3 . The fibrinous coagula are either held in suspen- 
sion or else separate out on standing; sometimes the entire urine is 
converted into a jelly-like mass. 

Other albumins are very rare. Xucleo-albumin is a proteid 
containing phosphorus, which occurs in minute trace in normal 
and many pathological urines. Mucin is closely allied to it, but 
yields proteid and carbohydrate when split up. It forms the deli- 
cate cloud so often seen in urines on standing, and is increased in 
many pathological conditions of the genito-urinary tract. Hist on 
and nucleo-histon have been found in a few cases of leukemia. 

Sugar. — Traces of glucose probably occur in every normal 
urine, but these are so minute that they escape detection with the 
ordinary tests. The ingestion of a large amount of sugar may lead 
to the so-called digestive glycosuria, especially in individuals who 
have a low tolerance for sugar, though they do not necessarily suf- 
fer from diabetes. The abnormal excretion of sugar may be 

1 Deutsch. Arch. f. klin. Med., 1901, p. 29. 

2 See S. Jellinek, Virch. Arch., vol. 177. Xo. 1. 

3 Quincke, Deutsch. Arch. f. klin. Med., vol. 79. Xos. 3 and 4. 



16 EXAMINATION OF URINE. 

divided into simple glycosuria, a temporary condition occurring 
witli some diseases of the nervous system and digestive tract, and 
after the use of certain drugs; and diabetes mellitus, a separate 
and distinct constitutional disease. Since there are several degrees 
of severity of the latter, and the mildest form disappears with diet, 
care should be taken to examine the urine voided after some 
saccharine articles have been ingested before passing a definite 
opinion. In doubtful cases the patient should be instructed to 
take a hundred grammes of glucose, as this quantity does not cause 
glycosuria in health. 

The urine of true diabetics may contain from a trace to as much 
as 10 per cent, of glucose. 

The color is generally pale, the specific gravity more than 1,0*25 
and the urea often above normal. It is important to note that the 
percentage of sugar present only rarely indicates the gravity of the 
case. A patient may excrete 5 or 6 per cent, and with proper 
diet his urine may become perfectly normal, while in another case 
the most careful selection of food will not cause the disappearance 
of a trace. The prognosis is also modified considerably by the 
presence of other bodies, such as acetone and diacetic acid. 

The relation of diabetes to pancreatic disease is still unsettled. 
In many of the severer cases advanced pancreatic disease is found 
at autopsy. Above all, the specific elements of the pancreas, the 
islands of Langerhaus, are destroyed. Yet there are many cases 
of grave diabetes where even microscopical examination of the 
organ fails to detect any change. 

The form of diabetes following the experimental injection of 
phloridzine is of special interest, since this drug seems to harm the 
renal cells directly, so that appreciable amounts of sugar are fil- 
tered from the blood. 

Compared with glucose, the other sugars play a very subordinate 
role. Lactose, or sugar of milk, is sometimes seen toward the end 
of gestation, and in nursing women with excess of milk in their 
breasts. It may be artificially induced by giving over 120 
grammes by mouth. Levulose may occur in conjunction with glu- 
cose in diabetes or independently. An important observation con- 
cerning this sugar has been made by Strauss. 1 He found that 
if 100 grammes of levulose and 500 grammes of water are given on 
an empty stomach to a patient suffering from hepatic disease, the 
urine collected during the following four hours will almost always 
contain levulose. Where the liver was normal, levulose appeared 
--Strauss, Deutsch. med. Wocli., 1901, 



ABNORMAL CONSTITUENTS OF THE URINE. 47 

in only a small percentage. Chajes 1 has examined a large number 
of cases, and finds levulosuria in hepatic disease in 86.9 per cent. ; 
in other disorders in only 15 per cent. 

Levulosuria under other conditions seems to be exceedingly rare. 
Thus Schlesinger 2 speaks of only five recorded cases where this 
sugar was voided spontaneously. One patient suffered from trans- 
verse myelitis, and the levulose was discovered by accident, while 
in the others typical diabetic symptoms were present. The family 
history showed diabetes on the maternal side in two. Obesity was 
a concomitant symptom in two, while the fifth was suffering from 
extreme nervousness. The excretion of levulose was very slight 
in all but one. In two cases dextrose was also voided. 

Maltose and laiose may also occur in diabetes, and the former 
has been met with in several cases of pancreatic disease. Various 
pentoses (rhamnose, xylose, arabinose) sometimes occur in urine, 
and are of no significance except that their presence has occasion- 
ally led to the wrong diagnosis of diabetes. 

Two bodies closely allied to sugar are glycuronic acid and 
inosit. The former is chemically a pentose-carbonic acid, and is 
intermediary in its constitution between pentose and hexose. It is 
never found free in the urine, but always combined with inclol and 
phenol, or with certain drugs (menthol, turpentine, chloral, mor- 
phine). According to P. Mayer, glycuronic acid must be regarded 
as a product of the incomplete combustion of sugar, and is often 
found in the urine of diabetics who have improved so much that 
their power of oxidizing sugar is partially restored. It has also 
been observed after poisoning with curare and acetone. 

Inosite is sometimes found when much water is ingested. 

Acetone.— Acetone is generally considered to be a decomposi- 
tion product of albumin, which may occur in traces in normal 
urine, especially after a purely proteid diet. Larger quantities 
are found in severe fevers, with much breaking down of proteid 
tissue; in the cachexias of malignant tumors, and in diabetes. 
Whenever sugar is detected in urine, the acetone test should be 
clone, as an appreciable quantity may signify an approaching 
coma. It will often be possible to avert this and to cause a dis- 
appearance of the acetone by adding carbohydrates to the diet. 
Acetonuria has also been observed in certain psychical and intesti- 
nal diseases. 

Diacetic Acid. — Diacetic acid has the same significance, and 

1 Chajes. Deutseh. med. Woch.. May 5, 1904. 

2 Arch. f. exp. Path. n. Pharmak.. 1903. 



48 EXAMINATION OF URINE. 

occurs under the same conditions as acetone. It is probably never 
found in health. 

/3-0xybutyric Acid. — /j-oxybutyric acid 1 is closely allied chem- 
ically to acetone and diacetic acid. If present in amounts of 
20.0 grammes or more in the urine, together with an excess of 
ammonia, diabetic coma is almost certain. 

Hemoglobin. — Hemoglobin may occur in the urine in the form 
of red-blood cells or dissolved. The latter condition is known as 
hemoglobinuria, and the variety of hemoglobin generally present 
is methemoglobin. It commonly occurs after the ingestion of cer- 
tain poisons, notably potassium chlorate and pyrogallic acid, after 
the transfusion of foreign blood, in extensive burns, and severe 
infectious diseases, especially malaria. In certain individuals 
general exposure to cold or the mere immersion of a limb in cold 
water will be followed by the discharge of bloody urine. Donath 
believes that the entire process here depends on a hemolytic action 
of the Wood-serum, caused by the presence of serum hemolysins. 

Melanin. — In patients suffering from melanotic tumors the 
urine will sometimes contain a dark-brown pigment or its chro- 
mogen, which turns dark after the urine has stood for some time. 
The detection of melanin is not an absolutely positive sign of 
melanotic tumor, as similar pigments occur in wasting diseases and 
malaria. If, however, a melanotic tumor has been extirpated, and 
melanin appears in the urine later, a metastasis is probable. 

Bile Pigments. — Bilirubin is the only bile pigment encoun- 
tered in urine, but the others may form from bilirubin if the urine 
has stood for some time. Bilinuria is common to all conditions 
associated with obstruction of the bile passages, such as catarrhal 
jaundice, stone of the common duct, cancer and tumors or 
adhesions of the neighborhood. Bilirubin may also be found in 
acute yellow atrophy, and sometimes in pernicious anemia, typhoid 
fever, etc. 

Bile Acids. — Bile acids are found in urine, together with bile 
pigments, and possess the same significance as these. 

Urobilin. — Two forms of urobilin are generally recognized, 
viz., normal urobilin (urochrome), obtained from the hydro- 
bilirubin eliminated by the intestinal walls, and present in every 
urine, and the closely allied pathological urobilin. This is found 
in the urine of fevers, and many other conditions, notably per- 
nicious anemia. There may also be some bilirubin, and the 
patients frequently have a slight icteric hue. 
1 Herte.r and Richards. Medical Xews. 1903. 



ABNORMAL CONSTITUENTS OF THE URINE. 



49 



Fats.— Small amounts of fat may occur whenever the renal cells 
undergo fatty degeneration. Larger quantities render the urine 
turbid (lipuria), and are seen wherever there is an excess of fat 
in the blood, as after large doses of oil, in some cases of fracture of 




Crystals of leuein (different forms). (Crystals of kreatinin chloride of zinc resemble the 
leucin crystals depicted at a.) The crystals figured toward the right consist of comparatively 
impure lencin. I From Charles : Chemistry. ) 

the bones, diabetes mellitus, eclampsia, etc. In the peculiar con- 
dition known as chyluria the fat occurs in emulsified form. It is 
generally associated with the presence of filar ia sanguinis ho minis 

Fig. 17. 




Tyrosin crystals. (Musser.) 

in the blood. In one case (D. Stiirtz) Eustrongijlus gigas was 
found, and rarely no parasite is present, but some distinct lesion 
of the kidney allows the fat to pass through. 

4 



50 EXAMINATION OF URINE. 

Cholesterin. — Though a normal ingredient of bile, cholesterin 
is usually not found in icteric urine, but in a number of patho- 
logical conditions of the genito-urinary tract. The crystals 
excreted are sometimes very large. 

Leucin and Tyrosin. — Both leucin and tyrosin are decomposi- 
tion products of albumin, and are formed abundantly during 
pancreatic digestion. They are encountered in the sediment of 
urines 'of acute yellow atrophy and other severe hepatic diseases. 

Cystin. — Cystin occurs only in exceptional cases in the urine, 
but is not associated with any definite disease. Like alkaptonuria, 
cystinuria probably depends upon a localized, specific disturbance 
in the katabolism of proteids. It is especially of interest in its 
association with cystin gravel or calculi, but, strangely, the cystin- 
uria may persist for years, even after the stones have been 
removed. The urine is peculiar in that it is often neutral or 
alkaline, of a peculiar greenish-yelloAV color and with a distinct 
odor of hydrogen sulphide. 

Alkaptonuria. — In the peculiar condition known as alkapton- 
uria the urine turns rapidly brown when exposed to the air and 
upon the addition of alkalies. Chloride of iron will give a tem- 
porary bluish-green color, while ammOniacal silver and Fehling's 
solution are reduced. It is not difficult, however, to distinguish 
such urine from diabetic urine, since it does not reduce bismuth, 
ferment, nor turn the plane of polarized light. The condition is 
generally congenital; the parents of the patients are often close 
blood connections, and there seems to be a close relation to that 
pathological lesion known as ochrinosis. The foreign substance 
in the urine is homogentisinic, and sometimes uroleucinic acid, 
whose mother substances are tyrosin and phenylalanin. Abder- 
halden and Falta found homogentisinic acid in the blood of a case 
of alkaptonuria. The cause of the disturbance underlying this 
condition was found to be neither in the intestinal canal nor in the 
process of absorption. 

Diazo Reaction. — In certain febrile diseases, notably typhoid, 
miliary tuberculosis and measles, a chromogen appears in the 
urine, which is converted into, a red pigment when the urine is 
treated with certain reagents. This reaction may be of the 
greatest value in the diagnosis of typhoid fever, since it may appear 
as early as the fifth or sixth day, when the Widal test is still nega- 
tive. Simon has examined a large number of cases, and has 
obtained positive results in 95 per cent, of typhoid cases, in 2 out 
of 16 cases of pulmonary tuberculosis, 3 out of 4 of septicemia, 2 



ABNORMAL CONSTITUENTS OF THE URINE. 51 

out of 4 of carcinoma, 1 out of 11 of pneumonia and in all typhoid 
relapses. In his cases of measles the reaction was not present It 
is stated that a diazo occurring in the course of a pulmonary 
phthisis indicates an extensive process, with grave prognosis. 

Dimethylamidobenzaldehyde Reaction. — In 1901 Ehrlich found 
that in various pathological conditions a cherry-red color will 
be obtained if the urine is shaken with a few drops of dimethyl- 
amidobenzaldehyde in acid solution. The resulting pigment 
can be extracted with chloroform or dichlorhydrin. With 
normal urines a reaction also occurs, but much less intense. The 
occurrence of the reaction is summarized by Simon as follows : A 
direct reaction of pathological grade does not occur in health. A 
positive reaction is most, commonly obtained in cases of tubercu- 
losis, but may also be seen in non-tuberculous urines, both febrile 
and non-febrile. It does not depend upon the presence of the body 
which gives rise to the diazo reaction. For its production, eleva- 
tion of temperature, gastro-intestinal disturbances and cyanosis are 
not essential. Common to all eases seems to be an increased kata- 
bolism of the tissue albumins. 

Pancreatic Reaction. — Alayo Robson and P. J. Cammidge 1 
have published their observations and researches on the chemistry 
of the urine in diseases of the pancreas. They state that the urine 
here very frequently contains glycerine, and that the glycerine can 
'be easily converted by means of hydrochloric acid into glycerose, 
which is then precipitated in the form of an osazone with phenyl- 
hydrazine hydrochlorate. The authors furthermore state that in 
some diseases of the pancreas the reaction is prevented by mercuric 
chloride, while in others this substance does not interfere, and that 
the size of the crystals and the rapidity with which they dissolve 
differ for different pathological lesions. J. H. Schroeder 2 states, 
however, that nitric acid, but not hydrochloric acid, can, under 
certain conditions, change glycerine into glycerose, and that it is 
against all laws of physics and chemistry to assume different sizes 
of the same crystals and different solubility as characteristic of 
different diseases of the same organ. 

Other Organic Principles. — In phosphorus poisoning and acute 
yellow atrophy of the liver, lactic acid may occasionally be 
found in the urine. In the latter condition there may also be 
some oxyamygdalic acid. Volatile acids (formic, acetic, butyric, 
proprionic) may also occur in febrile conditions and suppurative 

1 Lancet, March 19, 1904. 

- American Medicine. Sept. 3, 1904. 



52 EXAMINATION OF IR1XE. 

processes* Kosenfeld 1 believes their amount has some diagnostic 
significance, since he has found them in ulcer of the stomach and 
gastreetasy with normal or hyperacidity, and in carcinoma with 
stagnation and sub or anacidity ; while in stagnation due to old 
pyloric scars or gastroptosis with sub or anacidity they were 
diminished. Finally, certain very toxic ptomaines (cadaverin, 
putrescin) are found in rare instances. 

Gases. — Urines containing albumin or cystin will often develop 
a distinct odor of sulphuretted hydrogen on standing. Sometimes 
this decomposition already occurs in the bladder in otherwise nor- 
mal urines, due to the action of certain micro-organisms on the 
neutral sulphur. The term pneumaturia is generally applied to 
the discharge of urine containing an appreciable quantity of car- 
bon dioxide, as in diabetes where yeast formation has already 
taken place in the bladder. 

t Drugs. — Many of the common remedies appear in the urine, 
and can be detected with the ordinary tests. The discovery of 
lead, arsenic or mercury may clear up doubtful cases of poisoning. 
In addition to these, the following drugs give characteristic reac- 
tions : iodides, bromides, chlorate of potassium, the active princi- 
ple of rhubarb, senna and cascara sagracla, santonine, salicvlic acid, 
antipyrine, phenacetine, copaiba, urotropin, chloroform and car- 
bolic acid. After the prolonged use of sulphonal or trional, the 
urine may become dark-red in color, owing to the presence of 
hematoporphyrin. 

1 Deutseh. med. Woch.. March 26, 1903. 



CHAPTER V. 

CHEMICAL TESTS FOE NORMAL CONSTITUENTS. 

Nitrogenous Principles. — In experimental work it will often 
"be necessary to determine the total nitrogen of urine ; that is, the 
nitrogen yielded by urea, uric acid, the other purin bodies, krea- 
tinin, the amido-acids (chiefly hippuric acid), ammonia and the 
pigments. In practice, however, a urea estimation will suffice in 
most cases 
principles present. 



since urea forms over four-fifths of the nitrogenous 



Fig. 18. 




Kjeldahl's nitrogen apparatus. (Simon.) 



The method generally employed for determining the total 
nitrogen is that of Kjeldahl : Ten cubic centimeters of urine are 
heated on a sand-bath in a flask of hard glass, with ten cubic centi- 
meters of concentrated sulphuric acid and a few drops of copper 
sulohate solution until the mixture has become colorless or greenish 

(53) 



54 



EXAMINATION OF URINE. 



(about one hour). The flask should be inclined at an angle of 
45 °, and vigorous ebullition should be avoided. This procedure 
will convert all the nitrogenous principles into ammonium sul- 
phate. The flask is now connected with a distilling apparatus ; , 
and the contents distilled into another flask containing twenty 
cubic centimeters of half -normal oxalic or sulphuric acid, after the 
addition of forty cubic centimeters of soda lye of a specific gravity 
of 1.34. The distillation is interrupted when crystals of sodium 
sulphate begin to appear, or when about two-thirds of the solution 
has passed over. After the addition of a few drops of rosolic acid 

Fig. 19. 




o*r *> 



Apparatus for the determination of nitrogen., (Simon.) 



solution, the distillate is then titrated with half -normal sodium 
hydrate solution until the liquid remains red. The amount of 
nitrogen contained in ten cubic centimeters of urine is obtained by 
subtracting the number of cubic centimeters of soda solution 
employed from the amount of half-normal acid in the flask and 
multiplving the result by 0.007. 

Instead of sulphuric acid and copper sulphate, Gunning's 
mixture may be employed. This consists of 15 c.c. of concentrated 
sulphuric acid, 10 grammes of potassium sulphate and 0.5 
gramme of copper sulphate. 

Since difficulty may be experienced in properly heating the urine 



CHEMICAL TESTS FOB NORMAL CONSTITUENTS. 55 

with the sulphuric acid, the method of Will-Varrentrapp may be 
substituted, since it gives equally as accurate results. Ten c.c. of 
normal sulphuric acid, together with a few cubic centimeters of a 
1 per cent, alcohol phenolphthalein solution, are placed in a Will- 
Varrentrapp apparatus. Another flask on a sand-bath is filled 
one-half with dried soda-lime, protected with a hood, and then 5 
cubic centimeters of urine permitted to flow in. The two flasks 
are connected by means of a glass and a rubber tube, which is pro- 
vided with a stop-cock. The latter is now opened and the urine 
and soda-lime heated over the sand-bath for one-half to three- 
quarters of an hour. All nitrogenous principles will be decom- 
posed by the heat and soda-lime into ammonia, which then distils 
over into the acid. As soon as the heating is discontinued, the 
Will-Varrentrapp apparatus is connected with an aspirating bottle 
and air allowed to pass slowly through the entire system for fifteen 
minutes. The acid is finally titrated with normal sodium hydrate 
solution until the phenolphthalein turns red. The number of c.c. 
of solution employed is deducted from 10 ; the result multiplied by 
20, which will give the number of c.c. required to neutralize the 
ammonia from 100 c.c. of urine. The percentage of nitrogen is 
then calculated by multiplying by 0.014, but by 0.03 if desired in 
terms of urea. 

Whenever it is desired to ascertain the general distribution of 
nitrogen in the urine, the total nitrogen is first estimated according 
to Ivjeldahl : A portion of the urine is then precipitated with 
phosphowolf ramie acid, and the nitrogen determined in this pre- 
cipitate ; this corresponds to ammonia, the purin bodies, kreatinin 
and the pigments. The nitrogen in the filtrate will give the 
figures for urea and the amido-acicls. The urea itself is best 
determined according to Monger and Sjoquist (v. i.), the purin 
bodies after Arnstein's modification of Camerer's method (v. i.) 
and the ammonia according to Folin or Schlosing. The following 
average figures were obtained during health by A. Landau : Purin 
nitrogen, 1.01 per cent. ; ammonia nitrogen, 2.42 per cent. ; urea 
.nitrogen, 90.87 per cent. ; amido-acid nitrogen, 2.89 per cent. 

Urea. — If it is desired to demonstrate the presence of urea in a 
fluid, as in the vomitus or serum of uremia, etc., 20-25 cubic centi- 
meters are evaporated in a porcelain dish upon a water-bath to a 
thin syrup. Upon the addition of several cubic centimeters of 
concentrated nitric acid, nitrate of urea will crystallize out, which 
can be identified under the microscope as typical, superimposed, 
rhombic plates. By decomposing the salt with carbonate of 



56 



EXAMINATION OF URINE. 



barium, pure urea may be obtained, which will give the biuret 
reaction. 

Fig. 20. 




Urea nitrate crystals. (Krukenburg, after Kuhne.) 
FTG. 21. 




Doremus' ureometer. 



For the quantitative determination of urea, the method of 
Boremus is most convenient. A tube, consisting of a long, closed 



CHEMICAL TEXTS FOR NORMAL CONSTITUENTS. 5 i 

arm and a short, wide, open one, is filled with a solution of hypo- 
bromite of sodium, made by mixing 5 cubic centimeters of bromine, 
70 cubic centimeters of a 30 per cent, by volume solution of 
sodium hydrate and 180 cubic centimeters of water. The solution 
should not be kept more than a few days. One cubic centimeter 
of urine is then passed into the long arm by means of a specially- 
constructed pipette. The hypobroniite will decompose the urea 
into carbon dioxide, water and nitrogen; the carbon dioxide is 
absorbed by the excess of alkali present, while the nitrogen is set 
free, and its volume can be read off in terms of urea. In a later 
model of Doremus a graduated tube projects from the long arm- 
which takes the place of the pipette. In albuminous urines con- 
siderable frothing occurs.^ and it is always better to remove the 
albumin. While this method is but a crude one, it is sufficiently 
accurate for ordinary clinical work, especially if the urine is 
diluted, should it contain more than 1 per cent, of urea. The 
temperature and barometric pressure need not be taken into 
account, but at least half an hour should elapse before the reading 
is taken. 

The apparatus which Simon 1 recommends, although also a 
volumetric one, gives much more accurate results. It consists of a 
burette C, with an ascending rubber tube attached to the reservoir 
B, which can "He raised or lowered, as required. A descending tube 
leads to a wide-mouth bottle A, which contains the hypobromite 
solution. This is closed by a tightly-fitting stopper, to which a 
loop of platinum wire is attached, carrying a little glass bucket; 
|his can be swung from its support by tilting the bottle. After 
the -topper is removed from A, water is poured into B until the 
water level is visible above the point where the rubber tube is 
adjusted. About 25-30 c.c. of hypobromite solution are placed in 
the bottle A, and 2 c.c. of urine accurately measured into the 
bucket. The stopper is carefully adjusted, the water in B and C 
brought to the same level and the reading taken. The bucket is 
now dropped into the hypobromite solution by inclining A. The 
liberated nitrogen will collect in the burette and depress the level 
of the fluid, when, after twenty or thirty minutes, the pressure in 
C is equalized by lowering B until the water in both tubes occupies 
the same level, when the second reading is taken. The difference 
corresponds to the volume of nitrogen evolved from 2 c.c. of urine. 
To determine the percentage of urea, this figure must be divided 
by 354.3 and multiplied by 50. A table must be consulted to cor- 
rect for temperature and barometric pressure. 

1 Clinical Diagnosis. 



EXAMINATION OF URINE, 



Other areometers are Green's, Marshall's, Hueffner's and 
Squibb's. Only the last mentioned possesses advantages in being 
a very simple contrivance. It requires two- ordinary medicine 
bottles, A and B. B is closed by a doubly-perforated rubber stop- 
per, a straight tube passing through the upper aperture and con- 
necting with A, in which the nitrogen is evolved out of 25 c,c. of 
hypobromite solution and 2 c.c, of urine, which latter is contained 
in a small tube. Another tube, bent downward and carrying a 
clamp, passes through the lower aperture, and leads to a graduated 
cylinder. B contains just enough water for the bent tube to dip 
in. The clamp is opened, and the urine and solution mixed by 
inclining A. The nitrogen, as it escapes into B, will displace its 
volume of water, which flows into E, and can be readily measured. 
A table will then give the amount of urea. 



Fig. 22. 




Squibb's ureometer. 



In FolinV recent method urea is decomposed into ammonia and 
carbon dioxide by a concentrated solution of magnesium chloride. 

A very novel test is that of Miguel. 2 It is well known that urea 
is decomposed into carbonate of ammonia on standing, through the 
agency of micro-organisms. A ferment is isolated from the latter 
and dissolved to a clear solution. Equal quantities of this and of 
urine are mixed, and the ammonia determined at once, and after 
the mixture has been digested for two hours at 50° C. By sub- 
tracting the first from the second determination, the amount of 
ammonia corresponding to the urea present may be easily deter- 
mined. 

1 Zeitsch. f. physiol. Chemie,. vol. 22, p. 504. and vol. 36. p. 333. 
2 Oomptes Rendues., 1890. 



PLATE I 



FIG. 1. 




Uric Acid. (Musser.) 

A. Common forms. B. Amorphous urates. 
(Ob. D. and A., Oc. 4.) Drawn by J. D. Z. Chase 



% 



; 



2. 






rrf 



it*. 



Combination of Urie Acid and Calcium Oxalate. 
(Musser.) 

(Oc. 4, Ob. D.) Drawn by J. D. Z. Chase. 



CHEMICAL TESTS FOR NORMAL CONSTITUENTS. 59 

For more accurate work, Morner and Sjoquist have devised the 
following method : Five c.c. of urine and 5 c.c. of a mixture con- 
taining 10 grammes of chloride of barium and 3-4 grammes of 
caustic baryta to 100 c.c. of water are mixed in a flask with 100 c.c. 
of an alcohol-ether mixture (alcohol, 97 per cent, 2 volume; ether, 
1 volume), allowed to stand until the next day, filtered, washed 
with the alcohol-ether mixture and then evaporated with gentle 
heat. As soon as the volume has reached about 25 c.c, some water 
and milk of magnesia (magnesia usta 1, water 12) are added, and 
the whole heated until the vapor no longer reacts alkaline. The 
fluid and precipitate are washed into a flask with the aid of some 
dilute sulphuric acid, and the nitrogen then determined according 
to Kjeldahl. 

Uric Acid. — Fifty to 100 c.c. of urine are strongly acidified by 
the addition of hvdrochloric acid, when the uric acid will crvstal- 
lize out after several hours in the form of yellowish-brown crystals. 
These crystals are collected on a filter, washed with water and 
then transferred to a porcelain dish. If they are now heated care- 
fully with two or three drops of concentrated nitric acid until the 
acid has evaporated, the addition of a few drops of ammonia 
will give rise to a purple color; of potash lye, to a violet color 
(murexid test). On warming, the color will disappear rapidly 
(difference from xanthin bodies). 

Tichborne 1 has modified the test as follows: Some nitric acid 
is added to urine, and the whole evaporated on the water-bath. 
Circular bands of uric acid will form in the dish, and at one place 
the concentration of nitric acid will be just sufficient to bring 
about a purple color when the dish is held over ammonia water. 

Fpr quantitative analysis the following method is recommended 
(Hopkins) : Fifty c.c. of urine are rendered faintly alkaline with 
ammonia and gently warmed to about 40° C. Fifteen grammes of 
powdered ammonium chloride are then added, and the mixture set 
aside. At the end of two hours all the uric acid will have pre- 
cipitated in the form of its ammonium salt. The urine is then 
filtered, and the precipitate washed with a saturated solution of 
ammonium sulphate until the filtrate no longer gives a precipitate 
with silver nitrate. The filter-paper is then punctured, and the 
ammonium urate washed into a clean flask with the aid of some 
boiling distilled water. The salt is decomposed with 7 to 8 cubic 
centimeters of concentrated sulphuric acid, and the amount of 
uric acid finally determined by titrating with a twentieth-normal 

1 MonatsbJ. f. prakt Dermatol, 1888. 



60 



EXAMINATION OF URINE. 



solution of potassium permanganate (containing 1.570 grammes 
per litre) until the pink color persists; for at least thirty seconds. 
Each cubic centimeter of the reagent corresponds to 0.0037 



Fig. 23. 



0.1". 
0.178 
0.1*1 

0.184 
0.187 
0.1 'JO 



U.2U2 
0.200 

0.20s 

0.211 

o.ii.:. 

0.218 

0.221 

0.22:, 

0.22:- 

0.2 M 

0.2:,'.". 

0.2:> 

0.21- 

0.2ir. 

0.24V 

0.202 

0.20 

0.28 

0.3 

0.33 

0.3.-. 

0.38 

0.41 



gramme of uric acid. A final correction of 0.0003 
gramme for each 100 c.c. of urine is necessary. 

Folin's method is still more accurate — 75 c.c. of 
a reagent, consisting of 500 grammes of ammo- 
nium sulphate and 5 grammes of uranium acetate 
dissolved in 650 c.c. of water, with the addition of 
60 c.c. of a 10 per cent, solution of acetic acid, are 
added to 300 c.c. of urine. The mixture is filtered 
after five minutes, and the filtrate divided into two 
portions of 125 c.c, each of which is treated with 
5 c.c. of concentrated ammonia and set aside until 
the next day. The precipitated ammonium urate 
is then filtered off, washed with ammonium sul- 
phate and treated as before. 

Instead of adding sulphuric acid and titrating 
with potassium permanganate, hydrochloric acid 
may be added to the ammonium urate solution, and 
the acid not used in decomposing the salt retitrated 
with sodium hydrate. Or else hydrochloric acid is 
added to the ammonium urate, the solution then 
evaporated and the crystals dried and weighed. 
TIaycraft precipitates the uric acid with ammoni- 
acal silver solution and magnesia mixture, and 
determines the amount of silver by titrating with 
potassium sulphocyanide., This, however, will also 
throw down the purin bases. 

Although these methods are accurate, they are 
rather troublesome, and consume considerable 
time. Ruhemann has recently constructed a uri- 
cometer, which permits of a rapid estimation and 
is fairly exact. A long, cylindrical tube is filled 
up to certain marks with carbon disulphicle, and 
then with a solution containing iodine 1.5 grammes, 
potassium iodide 1.5 gmes. and absolute alcohol 
15 grammes in 185 c.c. of distilled water. On 
adding a certain amount of urine and shaking, the car- 
bon disulphide will become Of a dark brown copper color; 
with more urine the carbon disulphide will absorb all 
free iodine, and the mixture will look like urine. The adding 



Ruhemann':- 
urieometer. 



CHEMICAL TESTS FOR NORMAL CONSTITUENTS. 61 

of urine should be stopped as soon as the carbon disulpbide- shows 
only a slight reddish tint, because this will disappear entirely after 
repeated shakings. The test is finished when the indicator 
appears snow-white, a sign that all iodine has been neutralized by 
the urine. After the foam has settled, the proportion of uric acid 
is read off on a scale. While very convenient, the end reaction is 
rather indefinite, and requires considerable experience. 

A recent method of uric acid determination is that by J. Rudisch 
and F. Kleeberg. Like other methods, it is based' upon the fact 
that uric acid and the purin bases form a definite compound with 
silver in an ammoniacal solution of the latter in the presence of 
neutral salts of the alkaline and alkaline earth groups, preferably 
chloride of magnesium, lithium or ammonium. Uric acid will 
combine with silver in the proportion of one molecule of the former 
with one atom of the latter; the purin bases in the proportion of 
two molecules of xanthin to one of silver. The silver urate i- 
insoluble in strong ammonia, but the silver-purin salts are rapidly 
soluble. The solutions necessary are (1) a fiftieth-normal solution 
of silver nitrate, made by dissolving 3.3932 grammes silver nitrate 
previously heated to 120° C. for ten minutes in water, adding 75 
c.c. ammonia of specific gravity 0.90 and 10 grammes chloride of 
ammonia and diluting to one litre; (2) a fiftieth-normal potassium 
iodide solution, prepared by dissolving 3.32 grammes potassium 
iodide in a litre of water; (3) a nitrons-sulphuric acid mixture, 
prepared by adding 25 c.c. concentrated sulphuric acid to 75 c.c. of 
water, and then adding 1 c.c. fuming nitric acid; (4-) a starch solu- 
tion, and (5) ammonia water of specific gravity 0.90. In order 
to determine the amount of uric acid, 55 c.c. of silver solution are 
added to 110 c.c. of urine, and the whole diluted up to 220 c.c. with 
ammonia. After filtering two portions of 100 c.c, each are col- 
lected. In the meantime half a dozen small test-tubes are filled 
for about 1 centimeter with a mixture of roughly, two parts of 
nitrous sulphuric acid and one part of starch solution. To one of 
the portions of 100 c.c, iodide of potash solution is rapidly added, 
and after every addition of 2 c.c. a small amount is removed by 
means of a pipette and floated on the solution contained in the test- 
tube. The end reaction will manifest itself by the appearance of 
a blue ring, owing to the formation of iodide of starch. The exact 
end reaction is now determined with the second 100 c.c ; that is, if 
more than 10 c.c and less than 12 c.c. are employed in the first 
determination, 10 c.c. are run in at once ; then a few drops are 
carefully added until the exact point is reached. 



62 EXAMINATION OF URINE. 

In order to determine the purin bases, the same process is car- 
ried out, except that water, instead of ammonia, is used to dilute 
the urine plus silver nitrate solution. The final calculation is as 
follows: 0.3 c,c. is subtracted from the number of c.c. of iodide 
solution used, for correction; the resulting number of c.c. is then 
subtracted from the number of c.c. of silver nitrate solution 
employed. This figure multiplied by 0.00336 will give the 
amount of uric acid in 50 c.c. of urine. Thus, if 15.9 c.c. of 
iodide solution have been used for 100 c.c. urine mixture, 15.9 — 
0.3 = 15.6; 25 (the number of c.c. of silver solution in 100 c.c. 
mixture) — 15.6 = 9.4; 9.4 X 0.00336 — 0.0316 gramme uric 
acid in 50 c.c. of urine. For purin bases the number of c.c. corre- 
sponding to uric acid, previously determined, are subtracted from 
the new figure obtained and the result multiplied by 0.00152. 
Thus, if 14.2 c.c. iodide solution are used for 100 c.c. mixture, 
14.2 — 0.3 (the correction) = 13.9 ; 25 (the amount of silver 
solution contained in 100 c.c. mixture) — 13.9 = 11.1 ; 11.1 - — 
9.4 (the figure previously obtained for uric acid) = 1.7 ; 1.7 X 
0.00152 = 0.0026 grammes of purin bodies, in terms of xanthin, 
contained in 50 c.c. of urine. 

The following precautions are mentioned by the authors: 

(1) In making the test for iodine, the solutions should be absolutely 
cold, and it is preferable to place the test-tubes in ice-water. 

(2) The end reaction can be observed most accurately in daylight. 

(3) Many urines, if added to the nitrous-sulphuric mixture, will 
develop a reddish-colored ring at the point of contact. This color 
is due to the action of the acid on the coloring matter of the urine, 
and is noticed only when working with the weak ammoniacal solu- 
tion. If doubt exists as to the nature of the ring, it is only neces- 
sary to gently shake the test-tube, without causing the liquids to 
mix completely. Under these conditions the reddish ring dis- 
appears entirely, while the blue iodine ring becomes more distinct. 

(4) If the urine contains a uric acid deposit, this should be dis- 
solved by warming, or by the addition of lithium carbonate. 

(5) Albumin and sugar do not interfere, but iodide of potassium 
must be removed by adding silver nitrate in excess, and then a 
chloride to remove the excess of silver. 

The authors have tested their method by control estimations 
with the Ludwig Salkowski method for uric acid and the Arnstein 
modification of the Camerer method for purin bases, and have 
found only slight discrepancies. The writer has had occasion to 
try the method in two instances, and finds it comparatively simple, 



CHEMICAL TESTS FOR NORMAL CONSTITUENTS. 63 

but has had some difficulty in detecting the first appearance of the 
blue ring. 

Purin Bases. Arnstein's 1 Modification of Camerer's Method- 
— 240 c.c. of urine are treated with 30 c.c. of magnesia 
mixture (crystallized magnesium sulphate, 1 ; chloride of ammonia, 
2 : ammonia water, 4; water, 8) and filled up to 300 c.c. with 20 
per cent, ammonia. After shaking, the mixture is at once filtered. 
Two portions of the filtrate, of 125 c.c. each (= 100 c.c. urine), 
are treated each with 10 c.c. of ammoniacal silver solution (3 per 
cent silver nitrate, with the addition of some ammonia). The 
resulting precipitate is filtered with the aid of an air-pump, and 
washed with 250-300 c.c. of water until free of ammonia. ! The 
nitrogen is then determined in the precipitate according to 
Kjeldahl's method. The urine should be first freed | from 
albumin. 

Salkowski's method is preferable in many ways, since a nitrogen 
determination is not necessary. Five hundred c.c. of urine, free 
from albumin, are treated with 50 c.c. of magnesia mixture, and 
filled up to 600 c.c. with strong ammonia and filtered. 

To 540 c.c. of the filtrate, 30-35 c.c. of a 30 per cent, aqueous 
solution of silver nitrate are added. The precipitate, which should 
be gelatinous, is allowed to stand for an hour, then filtered from the 
urine, washed and transferred into a flask, acidified with a few 
drups of hydrochloric acid and split up with sulphuretted 
hydrogen. 

The next steps consist in heating the flask on a water-bath, filter- 
ing, washing the precipitate and evaporating the filtrate to dryness. 
The residue is then heated up to boiling with 25-30 c.c. dilute 
sulphuric acid. The fluid is permitted to stand sixteen to twenty 
hours, when the uric acid can be filtered off and washed with 
dilute acid. The filtrate and washings are then supersaturated 
with ammonia, precipitated with silver nitrate solution, filtered 
and washed. The amount of silver is -determined by incinerating 
the precipitate in a platinum crucible, dissolving the ash in nitric 
acid, titrating with one-fiftieth normal sulphocyanide solution. 
Each c.c. of this will correspond to 1.52 grammes xanthin. 

These complicated methods have been much, simplified, and 
quite recently a very practical purinometer has been placed on the 
market. It consists of a tall glass cylinder, divided into an upper 
graduated portion, separated from a lower one by a tap. With the 
tap at right angles to the tube, 90 c.c. of urine and. 20 c.c. of solu- 

x Zeitseh. f. pliysiol. Chemie, 1897, p. 426. 



64: 



EXAMINATION OF I BINE. 



Fig. 24. 



n 



tion Xo. 1 (magnesia mixture) are poured in, and the tap then 
opened. The phosphates will precipitate at once. In ten minutes 
they will have passed into the lower portion of the tubes ; the tap 
is again turned at right angles and solution Xo. 2 (silver nitrate) 
is added up to 100 c.c. The resultant precipitate of silver-purin 
should be pale yellow. If some silver chloride has formed, a few 
drops of ammonia may be added. The appara- 
tus is then kept in a dark place, and after 
twenty-four hours the number of c.c. occupied 
by the precipitate may be read off and compared 
with a table. The result will give percentage of 
purin nitrogen, inclusive of uric acid. 

Personal experience with the parinometei'has 
not been very favorable. It is difficult to read 
oft' the height of the precipitate accurately, since 
this tends to cling to the glass, and control tests 
with more accurate methods often give *lis- 
cordant results. 

Kreatinin. Weyl - Salkowski Test. — A few 
cubic centimeters of urine are treated with 
a 5 per cent, solution of sodium nitroprusside. 

W\J and then with a few drops of sodium hydrate* 
solution. Kreatinin will give rise to a deep red 
color, which is changed to ereeii on warming 
with glacial acetic acid. On standing, a deposit 
Purinometer. of Prussian blue is formed. 

The quantitative estimation is conducted 
as follows : ISO c.c. of urine are rendered alkaline with 
milk of lime, and then precipitated completely with chlor- 
ide of calcium. The mixture is then filtered, after enough 
water had been added to make 600 c.c. ; 500 c.c. of 
the filtrate, which should react faintly alkaline, are evap- 
orated to 10 c.c. on the water-bath, mixed with an equal 
volume of absolute alcohol, and brought up to 200 c.c. with alcohol. 
After filtering, 160 c.c. are treated with 1-2 c.c. of an alcoholic 
solution of chloride of zinc (sp. gr. 1.20). After three or four 
days the crystals of kreatinin-zinc-chloride are filtered off, dried 
and weighed. The result, multiplied by 0.6211, will give the 
amount of kreatinin present. 

Amido-Acids. — The only amido-acid normally present which 
can be estimated quantitatively is hippuric acid. A large quantity 
of urine is evaporated to syrupy consistence, and then extracted 



CHEMICAL TESTS FOR NORMAL CONSTITUENTS. t>5 

with alcohol. The alcohol is removed by distillation, the remain- 
ing solution acidified with acetic acid and treated with alcoholic 
ether. The ether is now distilled off, the remaining solution 
evaporated on a water-bath, the residue boiled with water, cooled 
and filtered. The filtrate is rendered alkaline with milk of lime, 
the excess of calcium removed with carbon dioxide. The calcium 
salts remaining in solution are decomposed with acid, and the 
solution then extracted with ether, which will dissolve out the 
hippuric acid. The crystals are dried and Aveighed after the 
ether has evaporated. In pathological conditions two other amido- 
acids — leucin and tyrosin — may occur (vide nifra). 

Oxalic Acid. — In order to demonstrate the presence of oxalic 
acid in the urine it is frequently only necessary to examine the 
sediment, as the crystals are characteristic. Since there may, 
however, be no crystals, even when large amounts are present in 
the urine, precipitation must be brought about by carefully neutral- 
izing with ammonia or by treating the urine with one-third its 
volume of 95 per cent, alcohol and setting aside for twenty-four or 
forty-eight hours. 

For quantitative work, 500 c.c. of urine are evaporated to 150 
c.c, and then shaken with 20 c.c. dilute muriatic acid and the 
same amount of a mixture of ether, nine parts plus alcohol one 
part, in a separating funnel. The ether is collected in a flask and 
distilled off, the remainder then heated on a water-bath until all 
traces of alcohol and ether have disappeared. The remaining fluid 
is filtered, and rendered alkaline with ammonia. Upon adding 1-2 
c.c. 10 per cent, solution of chloride of calcium and acidifying with 
acetic acid, crystals of oxalate of lime will separate out, and can 
then be collected on a filter, dried and weighed. 

.V somewhat better method has recently been recommended by 
Albahary. 1 Fifty c.c. of a 10 per cent, solution of sodium car- 
bonate are added to the entire urine of twenty-four hours. This 
is then concentrated on a water-bath to one-third its volume ; 20 
c.c. of a solution containing 10 per cent, magnesium chloride and 
20 per cent, ammonium chloride are added, with some purified 
animal charcoal, and the mixture further concentrated to one- 
fourth. The charcoal is removed by filtering, the filtrate rendered 
strongly alkaline with ammonia and allowed to stand for twelve 
hours. The mixture is then again filtered, and the filtrate acidi- 
fied slightly with acetic acid and treated with calcium chloride in 
excess. After twelve hours the calcium oxalate can be collected 

'Cliemiker Zeitung, 1903. p. 732. 



66 EXAMINATION OF URINE. 

on a filter, dissolved in sulphuric acid and determined by titration 
with potassium permanganate. 

Ferments. — Pepsine can readily be detected in the urine by 
digesting large quantities of urine with flakes of fibrin. By deter- 
mining the critical temperature — i. e., the temperature at which 
digestion will cease — the identity between gastric and urinary 
ferments can be established. 

Urochrome .— In order to obtain urochrome from normal urine, 
1-1.5 grammes dilute sulphuric acid are added to the litre of urine, 
which is then filtered and saturated with ammonium sulphate. 
The resulting flakes are treated with warm, ammoniacal, absolute 
alcohol, when the pigment will be obtained on evaporating the 
alcohol. An alcoholic solution will exhibit a greenish fluorescence 
when treated with ammonia and zinc chloride. 

Klemperer 1 measures the amount of urochrome present in urine 
by comparing its color with a test solution of echt-gelb (0.1 gramme 
dissolved in 1 litre of water; 5 c.c. of this diluted up to 90 c.c. with 
water will correspond to a 0.1 per cent, solution of urochrome). 
The color of normal urine voided in amounts of 1,500 c.c. in 
twenty-four hours corresponds to about 0.15 per cent, urochrome. 
If the amount of urine be diminished by excessive perspiration or 
diarrhea, the amount of urochrome will correspond to 0.3-0.4 per 
cent, urochrome. This deep tinge is evidence of sufficient func- 
tional activity on the part of the kidneys. In severe renal disease 
the urine will be less abundant, without being darker in color. It 
may be stated that the lighter the tinge, the more serious the 
pathological changes. • The color is particularly important in heart 
disease. 

Cardiac weakness, with marked venous stasis, will give dark 
urine as long as the kidneys are in fair condition. If the urine 
is light-tinged, the kidneys are beginning to fail, and the prognosis 
is unfavorable. 

Uroerythrin. — When urine is precipitated with lead acetate 
or barium chloride, a rose color will be imparted to the white 
precipitate in the presence of uroerythrin. This pigment is very 
unstable, but readily soluble in amyl alcohol. 

Indican. — A few cubic centimeters of urine are treated with an 
equal amount of Obermayer's reagent (2 pro mille solution of 
ferric chloride in concentrated hydrochloric acid) and set aside 
for a few seconds. If the mixture is now shaken with a small 
amount of chloroform, a distinct blue color will be imparted to the 
^erl. klin. Woch., April 6, 1903. 



CHEMICAL TESTS FOR NORMAL CONSTITUENTS. 67 

latter in the presence of indican. Instead of Obermayer's reagent, 
the urine may be mixed with an equal amount of concentrated 
hydrochloric acid and one or two drops of a strong solution of 
chlorinated lime. Bile and other pigments must first be removed 
by means of a solution of subacetate of lead. Biegler employs 
barium peroxide, which w T ill liberate peroxide of hydrogen in the 
presence of hydrochloric acid. 

In testing for indican, the chloroform will sometimes turn red 
instead of blue, indicating the presence of skatol, which has the 
same significance as indican. It is, however, much better removed 
with amyl alcohol. In other cases the red color will not be taken 
up with chloroform, and is then due to urorosein (an unimportant 
pigment) or skatol carbonic acid (detected by adding a few drops 
of hydrochloric acid and very dilute chloride of iron solution and 
boiling, when a cherry-red color will appear). In the presence of 
iodides the chloroform will be tinged violet 

For quantitative analysis, an approximate estimation from the 
depth of color of the chloroform will generally suffice. For more 
accurate work, Strauss has constructed a special separating funnel. 
Twenty c.c. of urine are first treated with 5 c.c. of a 20 per cent, 
lead acetate solution and filtered. Ten c.c. of the filtrate are 
shaken with an equal amount of Obermayer's reagent and 5 c.c. of 
chloroform in the funnel. The chloroform is drawn off, fresh 
chloroform added and the process repeated until no more indigo is 
extracted. Two c.c. of the combined extractions are then diluted 
with chloroform until the color corresponds with that of a standard 
solution. 

Ellinger 1 has recently recommended the following method: 
The urine, which should be acid in reaction, is treated with one- 
tenth its volume of liquid plumbi subacetatis and filtered. A given 
volume of the filtrate is mixed with an equal volume of Ober- 
mayer's reagent. The resulting indigo is extracted with succes- 
sive portions of chloroform by shaking the tube about two minutes 
after each addition. The volume of the filtrate should be such 
that not more than about 30 c.c. of chloroform are required. The 
chloroform extracts are allowed to stand a few minutes, filtered 
through a dry filter into a dry, perfectly clean flask and evaporated 
on a water-bath to dryness. The residue is washed two or three 
times with hot water, and dissolved in 10 c.c. of pure sulphuric 
acid by heating on the water-bath for five to ten minutes. The 
solution is then transferred to a flask containing about 100 c.c. of 
x Zeitsch. f. phys. Chemie, vol. 38, Nos. 1 and 2. 



68 f:\AMI\ATlo\ OF URIX.E. 

distilled water, and titrated with potassium permanganate solution 
(5 c.c. of a 0.3 per cent solution, diluted with 200 c.e. of water) 
until a clear, yellow color is reached. Each c.c. will correspond 
to 0.177 milligrams of indigo. 

Neutral Sulphur. — In order to determine the amount of neutral 
sulphur it is first necessary to estimate the total sulphur (A) 
and then the inorganic sulphur (B), and finally to subtract B 
from A. 

The amount of total sulphur is computed as follows: 100 c.c. of 
urine are treated with 12 grammes of a mixture of 12 grammes of 
sodium and potassium carbonate (11 : 11-) and evaporated to dry- 
ness in a nickel crucible. The residue is fused thoroughly , allowed 
to cool and extracted with hot water. The residue is filtered off 
and filtrate and washings treated with a few crystals of potassium 
permanganate. After heating for about fifteen minutes, concen- 
trated hydrochloric acid is added until the reaction is distinctly 
acid. The solution is then brought to the boiling point and treated 
with about 20 c.c. of a saturated solution of barium chloride. 
Finally the barium sulphate is collected and weighed. The 
amount multiplied by 0.4206 will give the amount of sulphur in 
terms of sulphuric acid, by 0.34335 in terms of sulphuric anhy- 
dride and by 0.13744 as actual sulphur. 

Chlorides. — Chlorides are detected in urine by acidifying with 
nitric acid and adding a few drops of 10 per cent, solution of silver 
nitrate. The reaction may be expressed in the following terms : 
Heavy precipitate, slight precipitate, turbidity, faint turbidity. 
For ordinary purposes the following method is a fair quantitative 
test : Ten c.c. of urine are treated with a few drops of potassium 
chromate solution, and then titrated with a one-tenth normal solu- 
tion of silver nitrate until a faint orange tint no longer disappears 
on stirring. Uric acid, the xanthin bases, iodides and bromides 
will also react with silver nitrate, and if these substances are 
present in large amounts too high figures will be obtained. 

In case iodides and bromides are present, the iodine and bromine 
should be liberated by the addition of potassium nitrite and sul- 
phuric acid, and then extracted with carbon disulphide. After 
extraction the nitrous acid is decomposed by the addition of a little 
urea, and the solution neutralized with sodium carbonate. 

Method of Salkowski-Volhard i 1 Ten c.c. of urine are diluted 
with 50 c.c. of distilled water, and acidified with 4 c.c. of nitric 
acid. From a burette 15 c.c. of a standard solution of silver 
: Zeitsch. f. physio]. Chemie. vol. 1. p. 16. and vol. 2. p. 307. 



CHEMICAL TESTS FOR FORMAL CONSTITUENT®. 69 

nitrate are then added ( 29.059 grammes of silver nitrate, previ- 
ously heated, to 1 litre of water ; 1 c.e. = 0.01 gramme of sodium 
chloride), the mixture thoroughly agitated and diluted with water 
up to 100 c.e. The resulting silver chloride is removed by filtering 
through a dry filter into a dry flask. Eighty c.e. of the filtrate 
are then mixed with 5 c.e. of an ammonia-ferric alum solution 
(saturated at ordinary temperature), and titrated with sulpho- 
cyanide of potash solution (6.6 grammes to 1 litre) until a slight 
reddish tinge is seen. On multiplying the result by y 2 and deduct- 
ing from IT), the number of grammes of sodium chloride in 100 
c.e. of urine will be obtained. 

If the proper facilities are at hand, the method of Xeubauer and 
Salkiwski 1 is very simple and accurate. Ten c.e. of urine are 
evaporated to dryness in a platinum crucible, at a temperature 
slightly below 100° C. (e. g., on a- water-bath), after the addition 
of a little exsiccated carbonate of soda and 1 grammes of nitrate 
of potassium. The residue is carefully heated at a moderate tem- 
perature, to destroy the organic matter, then dissolved in distilled 
water and neutralized with nitric acid. The chlorides can now 
be estimated by a simple titration with standard silver nitrate 
solution. Albumin and sugar should first be removed. 

Sulphates. — Preformed sulphates are detected by acidifying a 
small amount of urine strongly with acetic acid and adding barium 
chloride, when a cloud of white precipitate will be obtained. Con- 
jugate sulphates are demonstrated by treating 25 c.e. of urine with 
an equal volume of a solution consisting of two parts of saturated 
barium hydrate and one part of saturated barium chloride and 
filtering. In the presence of conjugate sulphates the filtrate will 
show a precipitate if strongly acidified with hydrochloric acid and 
boiled. 

In order to determine the amount of preformed and conjugate 
sulphates, the total sulphates are estimated in one portion and the 
conjugate sulphates in another ; the difference between the two 
gives the preformed sulphates. 

Total sulphates are estimated as follows : 100 e.c. of filtered 
urine are boiled for ten minutes with 10 c.c. of muriatic acid, then 
mixed with hot chloride of barium solution (10-15 c.c), and 
allowed to stand until the next day, when the precipitate is filtered 
off and washed twice with absolute alcohol and once with ether to 
remove pigments. The precipitate is heated in a platinum 
crucible until it appears perfectly white, and finally weighed. For 
calculation, see under Neutral Sulphur. 

1 Pfliiger's Arch., vol. 6. p. 214. 



70 EXAMINATION OF URINE. 

For the quantitative estimation of conjugate sulphates, 100 c.c. 
of urine are mixed with 100 c.c. of an alkaline solution of barium 
chloride (see above), and filtered to the 100 c.c. mark. Dilute 
hydrochloric acid is now added, and the whole boiled until the 
barium sulphate has settled and the supernatant liquid is clear. 
The precipitate is filtered off, washed, dried and weighed as above. 
The weight, multiplied by 2 and deducted from the amount found 
by the first method, indicates the quantity of preformed sulphates. 

Phosphates. — To demonstrate the presence of earthy phosphates, 
it is only necessary to render the urine alkaline with ammonia, 
when a flocculent precipitate will occur. To demonstrate alkaline 
phosphates, the urine is now filtered, acidified with acetic acid 
treated with a few drops of ferric chloride or uranium nitrate 
solution or with magnesia mixture, when a white precipitate will 
form. 

For quantitative analysis, 50 c.c. of urine are treated with 5 c.c. 
acetic acid mixture (sodium acetate 100, glacial acetic acid 30, 
water to make 1,000), heated to boiling and titrated with a solu- 
tion of uranium nitrate of such strength that 20 c.c. = 0.1 
gramme P 2 5 (44.78 grammes to the litre). A number of drops 
of potassium ferrocyanide solution are placed on a porcelain plate. 
After every addition of uranium solution to the boiling urine a 
drop of the mixture is mixed with a drop of ferrocyanide on the 
plate. The end reaction is indicated by the presence of a brown 
color. By multiplying the number of c.c. used by 0.01, the per- 
centage of phosphates present will be obtained. 

In order to determine the alkaline phosphates alone, 200 c.c. of 
urine are rendered strongly alkaline with ammonia, and set aside 
for several hours, after which the precipitated earthy phosphates 
are filtered off, washed with dilute ammonia and transferred to a 
beaker by perforating the filter and washing with water containing 
a few drops of acetic acid. They are then dissolved in as little 
acetic acid as possible, and titrated with uranium solution as above. 
The difference between the result and the total phosphates will 
give the earthy phosphates. 

Nitrates. — Sodium, potassium, calcium, magnesium and iron are 
never estimated in the ordinary examination of urine. For details, 
see text-books on quantitative analysis. 

Ammonia. — An excellent method for estimating the amount of 
ammonia in urine is that of Folin. Ten c.c. of urine are diluted 
to about 450 c.c, and boiled with about 0.5 gramme of burnt 
magnesia. The distillate is received into a flask containing 



CHEMICAL TESTS FOB NORMAL CONSTITUENTS. 71 

decinormai sulphuric acid for forty-five minutes, into a second 
flask with acid for another forty-five minutes. The first flask will 
contain all the alkali obtained from the ammonia plus a small 
amount from urea. The second flask receives only a small amount 
from urea, so that by subtracting (b) from (a) correct figures 
will be obtained. Titration is carried on with alizarin as 
an indicator. 

Schlosing's method: 25 c.c. of urine are placed in a flat dish, on 
the plate of an exsiccator. Above this dish a smaller one, con- 
taining 10 c.c. of a normal solution of sulphuric acid, is placed. 
Ten cubic centimeters of milk of lime are added to the urine, the 
bell carefully adjusted, and the mixture allowed to stand for three 
or four days. The excess of acid remaining is then titrated with 
one-fourth normal sodium hydrate, using as an indicator methyl- 
orange. The number of c.c. used is subtracted from 40 ; by then 
multiplying with 4.25, the number of milligrams of ammonia con- 
tained in 25 c.c. urine will be obtained. The urine should be per- 
fectly fresh, and if concentrated or albuminous, at least five to 
eight days should be allowed to elapse before the acid is titrated. 



CHAPTER VI. 

QUALITATIVE AND QUANTITATIVE TESTS FOR ABNORMAL 

CONSTITUENTS. 

Serum Albumin. — Before testing for albumin, all urines should 
be perfectly clear, as otherwise minute traces will be over- 
looked. Urines rendered turbid by bacterial growth frequently 
cannot be filtered directly, but must first be shaken with charcoal, 
Fuller's earth, burnt magnesia or talcum. All these substances 
may, however, carry down with them minute traces of albumin, so 
that it is desirable to examine every urine as fresh as possible. 
When the turbidity is due to urates, simple warming will suffice, 
since most albumin tests also react with water ; but it may be 
desirable to also dilute the urine. 

A peculiar and hitherto undescribed behavior of albuminous 
urines is mentioned by Hallauer. If normal urine is concentrated 
on the water-bath to half its volume and albumin then added, the 
boiling test will be strongly positive, but the ring and ferrocyanide 
tests absolutely negative. As soon as water is added a turbidity 
will appear. If the urine is still further concentrated to one- 
fourth its volume, even the boiling test will be negative. The 
substances which interfere with these reactions are, for the ring 
test, urea ; for the boiling test, urea and neutral salts, and for the 
ferrocyanide reaction, the phosphates. 

It is thus necessary to dilute concentrated urines before testing. 
This applies also to urines rich in urates, as many of the albumin 
tests will tend to throw these down. The reaction of the urine in 
every case should be acid. This may be effected by a few drops of 
acetic acid. 

1. Hellers Ring Test. — A few c.c. of urine are layered 
over concentrated nitric acid, contained in a test-tube or a small, 
conical glass. In the presence of albumin, a sharply-defined white 
ring will appear at once, or after a few minutes, at the surface of 
contact. (Plate II.) 

. This test will reveal one part of albumin in 30,000 of urine, but 
is open to a number of objections: 1. In concentrated urines a 
crystalline ring of urea nitrate may form. This is prevented by 
diluting the urine. 2. If much uric acid is present, a ring of 

(72) 



PLATE II. 



FIG. 2. 



FIG. 4. 






FIG. 1. 




^TZ: 



FIG. 3. 



FIG. 3. 



--. I, ; j _^J, tm — 



TESTS FOR ABNORMAL CONSTITUENTS. 73 

urates will form, but this is somewhat above the surface of contact 
and disappears on warming. 3. A rather diffuse ring, soluble in 
alcohol, occurs after the use of copaiba, tolu balsam and oil of 
santal. 4. Urines containing mucin and nueleo-albumins show a 
ring in about the middle of the layer of urine, which will dissolve 
on shaking the test-tube. 5. The nitric acid will oxidize the pig- 
ments, and will give rise to colored rings, which cannot, however, 
be mistaken for the albumin ring. 

The ring test gives more information about the urine than any 
one test. Even in the presence of albumin, an excess of uric acid 
will show itself by the appearance of a distinct white ring above the 
zone of contact within five to ten minutes, while an absence of this 
ring will argue in favor of a diminished amount. 

With more than 25 grammes of urea, an appearance like hoar- 
frost will be noted on the sides of the vessel, while with -15 or 50 
grammes the nitrate will crvstallize out. Urine eontaininc; bile 
will show a play of colors (of which the green is most character- 
istic), especially if the nitric acid contains traces of nitrous acid. 
Urobilin will give a ring of distinct mahogany color; indican a 
violet ring. 

2. Boiling Test. — Five to 10 c.c. of urine are boiled, after 
which 5-10 drops of nitric acid are added, if a precipitate is 
formed on boiling, which does not dissolve upon the addition of 
acid, or if the precipitate only appears after the acid has been 
added, albumin is present. Sometimes urates precipitate out 
(avoid by diluting the urine), and occasionally resinous bodies will 
appear, but these dissolve readily on the addition of alcohol. If, 
after addition of nitric acid, the urine turns a distinct yellow and 
a white precipitate forms on cooling, the presence of albumoses is 



DESCEIPTIOX OF PLATE II. 
The Nitric Acid Test as Applied to the Urine. 

Fig. 1. — The light colorless ring in the clear urine above shows a slight increase 
in the amount of uric acid ; the large white band denotes a large amount of albu- 
min, bordering upon a colored ring, referable partly to indican (blue) and partly 
to urorosei'n. 

Fig. 2. — The light ring in the clear urine above denotes a slight increase in the 
amount of uric acid. The bluish-black band is referable to an enormous increase 
in the amount of indican. (Ileus.) 

Fig. 3. — The broad, light band in the clear urine above is referable to an enor- 
mous increase in the amount of uric acid. ( Laparotomy. ) 

Fig. 4. — The color-play referable to the presence of bilirubin is shown in a dia- 
grammatic manner. 

Fig. 5. — The colored ring is referable to the presence of normal urinary coloring 
matter. 



74 EXAMINATION OF URINE. 

probable, since the urates, which might cause confusion, are gener- 
ally of a dirty brown color. 

A better way to perform the boiling test is to fill a test-tube two- 
thirds full of clear urine, and then to boil only the upper layers. 
A turbidity or precipitate which does not disappear, but becomes 
more distinct upon the careful addition of one or two drops of 2 
per cent, acetic acid, is referable to albumin. 

The urine may also be treated before boiling with a few drops of 
acetic acid until a distinctly acid reaction is obtained, and then 
with one-sixth its volume with saturated solution of magnesium 
sulphate or sodium chloride. Carried out in this manner, the test 
is absolutely certain. 

3. Sulphosalicylic Acid ( Salicylsidphonic Acid). — One of the 
simplest, most convenient and accurate of tests is performed by 
adding a pinch of sulphosalicylic acid to a few c.c. of clear urine 
in a test-tube. In the presence of albumin, a turbidity or white 
precipitate will form at the bottom of the tube. The test is espe- 
cially recommended to the practitioner, as it necessitates only a 
small vial, with acid and a test-tube, and can thus be readily per- 
formed at the bedside. Alkaline urines should first be acidified 
slightly with dilute acetic acid, and warmed to drive off the gas. 
Albumoses and resins are also precipitated, but the former dis- 
solve on warming and the latter upon the addition of alcohol. 

Many books incorrectly state that urates are not precipitated, 
but in concentrated urines a granular deposit often forms on the 
sides of the tubes, or a white precipitate some distance above the 
layer of acid, which readily dissolves on heating. With minute 
traces of albumin, a turbidity is only apparent after several 
minutes. The test is one of the most delicate we possess ; it will 
be positive with one part of albumin in about 60,000 of urine. 

Jf. Ferrocyanide Test. — Five to 10 c.c. of urine are rendered 
strongly acid with acetic acid, after which 2-5 drops of a 10 per 
cent, solution of ferrocyanide of potash are added. In the pres- 
ence of albumin, a turbidity or flocculent precipitate will form. 
In case a turbidity or precipitate is noticed before the addition of 
ferrocyanide, this is due to mucin or urates, and the urine 
should be filtered. An excess of ferrocyanide must be avoided, as 
it tends to dissolve albumin. Very concentrated urines may be 
negative pure, and positive when diluted, since the precipitate is 
somewhat soluble in solutions containing a high percentage of salts. 

Albumoses and resins behave as in the previous test. 

This test will detect albumin in a dilution of 1-50,000. It can 



TESTS FOR ABNORMAL CONSTITUENTS. 75 

also be employed as a ring test by mixing a few c.c. of dilute acetic 
acid with several drops of ferrocyanide solution and carefully 
layering over the urine. 

Potassium platinocyanide may be substituted for the ferro- 
cyanide. 

5. Spieglers Test. — Spiegler's 1 reagent consists of corrosive 
sublimate, 8.0 ; tartaric acid, 4.0 ; glycerine, 20.0 ; distilled water, 
200.0. Urine strongly acidified with acetic acid is allowed to float 
upon a few c.c. of this reagent, when a white ring will form. This 
test is one of the most delicate we possess, showing 1 part of 
albumin in 500,000 of urine ; but if a small amount of salt only is 
present, it is less reliable. It also possesses the disadvantage that 
mucinous substance may be thrown down. In Jolles' modification 
5 c.c. of urine are shaken with 1 c.c. of 30 per cent, acetic acid and 
4 c.c. of a reagent consisting of sublimate, 10.0 ; succinic acid, 
20.0 ; sodium chloride, 10.0 ; distilled water, 500.0. This is com- 
pared with another test-tube containing the same amount of urine, 
with 1 c.c. of acetic acid and 4 c.c. of water, since the acid will 
throw down the mucin. Urines containing iodine will throw down 
mercuric iodide, which is soluble in alcohol. Albumoses and 
nucleo-albumins are also precipitated. 

Rossler has recently used Jolles' modification of Spiegler's 
test to determine if the albumin is of renal or other origin. He 
employs the test as a quantitative one by determining in how 
strong a dilution a ring will still form. Albumin due to nephritis 
will increase in amount after exercise or exertion, while albumin 
due to pus cells, etc., will remain the same. 

6. Trichloracetic Acid. — By means of a pipette, 1-2 c.c. of an 
aqueous solution of trichloracetic acid of specific gravity 1.147 are 
carried to the bottom of a test-tube, containing the filtered urine. 
In the presence of albumin, a white ring will form at the zone of 
contact,. Albumose and uric acid, if excessive, are also precipi- 
tated, but dissolve on heating. 

7. Roberts' Test. — Roberts' solution is composed of one part of 
strong nitric acid and five parts of a saturated solution of magne- 
sium sulphate. It is used in a manner similar to the nitric acid 
in Heller's ring test, and is subject to the same disadvantages, 
since it also throws down nucleo-albumin and mucin. The latter, 
moreover, is not dissolved as quickly as with pure nitric acid. It 
is less sensitive, and its only advantage is that it is not as corrosive 
nor as dangerous to handle. 

1 Deutsch. med. Woch, May 7, 1903. 



76. EXAMINATION OF URINE. 

Other Tests. — Carres places into a small test-tube 3-5 c.c. of a 
25 per cent, aqueous solution of resorcin, and floats the urine to 
be examined over this with a pipette. In the presence of albumin, 
a white band will form at the zone of contact. A number of nor- 
mal and abnormal urinary ingredients will also give rise to a white 
band, which is, however, said to dissolve on applying heat. The 
test is very sensitive, and reveals albumin where nitric acid has 
failed. 

Riegler has discovered that beta-naphthol sulphonic acid pos- 
sesses the property of precipitating all proteid substances. The 
reagent is prepared by dissolving 10 grammes of the crystals in 
200 c.c. of distilled water, and then filtering. Five to 6 c.c. of 
the suspected urine are placed into a test-tube, and 20-30 drops of 
the reagent are then added. In the presence of albumin, turbidity 
or precipitation occurs at once. The reagent is very delicate, 
since 1 part of albumin in 40,000 of water will still give a distinct 
turbidity. The precipitate does not disappear on boiling, while 
albumoses, which are also thrown down, will redissolve when 
heated. By means of specially-constructed albuminometers, the 
reagent may also be used for the quantitative determination of 
albumin. Instead of beta-naphthol sulphonic acid, asaprol may 
be employed, but the urine must be acidulated first. 

When no other reagents are at hand, alcohol will act as a fairly 
delicate test for albumin. It should be floated on the urine, when 
a white ring will appear at the surface of contact. 

If a small crystal of meta phosphoric acid (IIPOo) be dropped 
into albuminous urine, the albumin will precipitate out as a white 
cloud. This test is not very delicate (1 : 1,000), and, like cold 
nitric acid, throws down a number of other substances. It pos- 
sesses the advantage, however, of being solid when kept well 
stoppered. 

Instead of meta phosphoric acid, picric acid may be used in sub- 
stance or solution. It also precipitates albumose, peptone, mucin, 
nucleo-albumin, resins and urates. 

Other tests of little practical importance are the phenol and 
tannic acid tests, and those with Tanret's reagent, phosphotungstic 
or phosphomolybdic acids. Many attempts have been made to 
introduce reagents in some convenient form for bedside use. 
Thus, Paw recommends two tablets, consisting of citric acid and 
ferrocyanide of potassium, respectively, while Stutz-Furbringer's 
gelatine capsules contain bichloride of mercury, chloride of sodium 
and citric acid. A test-paper for the detection of albumin con- 



TESTS FOR ABNORMAL CONSTITUENTS, , , 

sists of thick blotting-paper, which is impregnated (Xo. 1) with 
citric and (Xo. 2) with potasso-mercuric iodide. When testing for 
albumin, Xo. 1 i.s first added to the urine, and then Xo. '2. Though 
convenient, these methods should not be employed, since they lack 
in accuracy. Some of the methods described are so simple and 
require so little apparatus that there can be no excuse for resorting 
to test-paper, etc. 

Summary. — It will be seen from the foregoing that none of the 
albumin tests are ideal, since they all throw down other substances 
closely allied to albumin, besides other foreign ingredients. 
Although albumoses, urates and resins can be easily distinguished 
from albumin, considerable difficulty often arises in distinguishing 
feetween nucleo-albumin and serum albumin. It is unfortunate 
that there is as yet no simple test for either of these substances, 
since it is often of the greatest importance to decide if the albumin 
is renal or nuclear in origin. 

The following 1 table will give an idea of the delicacy of the vari- 
ous tests : 

Nitric acid ( ring test )...." 1-30.000 

Heat and acetic acid 1-50,000 

Sulphosalicylic acid 1-60.000 

Feirocvanide test 1-50.000 

Spiegler's test 1-500,000 

Trichloracetic acid 1-75.000 

Roberts' test 1-15,000 

Resorcin test 1-50,000 

Beta-naphthol sulplionic acid test 1-40.000 

Metaphosplioric acid test 1-1.000 

Quantitative Analysis of Albumin. — In many cases the intensity 
of the above reactions will eive a fair idea of the amount of 
albumin present. Where greater accuracy is desired, the follow- 
ing may be employed, though none of them are ideal : 

Esbaclis Method. — Special graduated tubes are used, which are 
filled up to the mark U with urine, and the mark R with Esbach's 
reagent, consisting of picric acid, 10 grammes ; citric acid, 20 
grammes; distilled water, 1,000 c.c. The urine and reagent must 
be mixed very carefully by inverting the tube about a dozen times. 
At the end of twenty-four hours the precipitate will have settled to 
the bottom, and the amount can be read off in so many parts per 
thousand. The- urine should be acid, and must be diluted if it 
contains more than 7 pro mill, albumin or is of a specific gravity 
higher than 1,010. 

Since uric acid and other bodies will also precipitate, and the 
height of the precipitate will vary considerably with the tempera- 



78 EXAMINATION OF URINE. 

ture, the method is extremely crude. Recently attention has been 
directed to the fact that with some urines an abundant precipitate 
of picrate of kreatinin -potassium may form. This can, however, 
be recognized under the microscope by its crystalline structure. 

Method of Brandenburg. — This method depends upon the fact 
that the lowest dilution of albumin urine which will give a ring 
with cold nitric acid is 0.033 / 00 . Four dilutions of urine are pre- 
pared and tested separately : A = urine diluted 10 times ; B = 
A + 2 parts of water ; C = B -(- 4 parts of water, and D — C + 
1 part of water. A ring in three minutes 

with A = 0.33 °/oo } 
" B= 1.0 °/ 00 
" 0= 5.0 °/ 00 
" D = 10.0 °/oo 



y albumin. 



Other dilutions can, of course, be made if necessary. 

Method of Wassiliew. — Ten to 20 c.c. of urine are diluted up 
to 50 c.c. with distilled water, treated with two drops of a 1 per 
cent, aqueous solution of an aniline dye known as Echtgelb, and 
then titrated with a 12.5 per cent, solution of sulphosalicylic acid 
until a distinct brick-red color. is obtained. The number of c.c. 
used multiplied by 0.00006 will indicate the amount of albumin 
in the 10 or 20 c.c. of urine examined. Vogel has recently tested 
this method, and has found it far from accurate. 

The end reaction is by no means an easy one to determine, espe- 
cially if the quantity of indicator recommended by Wassiliew, two 
drops, is employed. It was found that the use of 10-12 drops 
produced a much sharper end reaction, without any apparent 
decrease of sensitiveness. The most advantageous technic found 
by Vogel is as follows: If necessary, the urine is acidified with 
acetic acid, and 10 c.c. each are measured out into several evaporat- 
ing dishes. After the addition of the indicator, the reagent is run 
in very slowly from a burette, with constant stirring, as the union 
of acid and albumin is somewhat slow. The first portion tested is 
taken as control, and after the end reaction is reached, as denoted 
by the production of a red color, which is not deepened by the 
addition of a further drop, a slight excess is run in. Titration is 
then carried out in the other dishes until the same shade of color is 
obtained. 

In order to control the results, a number of gravimetric estima- 
tions were made. Where the amount of albumin was above 0.15 
to 0.2 per cent.; fairly constant figures were obtained, but with 



TESTS FOR ABNORMAL CONSTITUENTS. < 9 

less the error was so high that the sulphosalicylic acid method can 
lay no claim whatever to accuracy. Even normal urine requires a 
certain amount of sulphosalicylic acid before the end reaction is 
obtained, but this is not a constant factor. 

By Boiling. — This method, though troublesome, is at present the 
only accurate one we possess. ■ A small sample of urine is boiled 
in a test-tube, filtered and the filtrate tested with ferrocyanide of 
potash and acetic acid for albumin. If negative, the entire quan- 
tity (500-1,000 c.c.) should be boiled; but if positive, 50 per cent, 
acetic acid should be added, drop by drop, until boiling will com- 
pletely precipitate all albumin present. The urine is then poured 
on a dried filter of known weight, care being taken that none of the 
albumin will remain behind in the flask. The precipitate should 
then be washed until the filtrate no longer turns turbid with silver 
nitrate and nitric acid. Fats are removed by alcohol and ether; 
finally the filter and its contents are dried at 120-130° C. until a 
constant weight is obtained. If still greater accuracy is desired, 
the precipitate is incinerated so that the amount of mineral ash 
present may be deducted from the weight found. 

Other Methods. — The differential density method consists in 
taking the specific gravity of urine before and after the removal of 
albumin by heat and acetic acid. The decrease in the specific 
gravity multiplied by 400 will indicate the number of grammes of 
albumin in 100 c.c. of urine. 

Esbach's method has been modified by centrifuging the precipi- 
tates in special graduated tubes, instead of waiting twenty-four 
hours until the precipitate has settled. Very recently two new 
methods have been suggested, one depending on the change of the 
index for refraction if albumin is present, and the other on the 
ultramicroscopic examination of a drop of urine. Since, however, 
they necessitate very - expensive apparatus, they will hardly come 
into general use. 

Serum Globulin. — It is generally assumed that serum globulin 
occurs in two forms, viz., euglobulin and pseudoglobulin. These 
are detected as follows : The phosphates are filtered off after pre- 
cipitation with ammonium hydrate. The filtrate is then treated 
with an equal volume of saturated ammonium sulphate, when any 
precipitates will be referable to serum-globulin. For quantitative 
estimation, the precipitate is collected, washed with half-saturated 
ammonium sulphate, dried and weighed. 

Albumoses. — Albumin must first be removed by boiling with 
an equal amount of 10 per cent, trichloracetic acid and filtering 



'80 EXAMINATION OF URINE. 

while hot. . Ordinary acetic acid will not do, since this would 
change some albumin to albnmose. Fifty c.c. of urine are acidi- 
fied in a beaker with 5 c.c. of hydrochloric acid, precipitated with 
2-3 c.c. of 10 per cent, phosphotungstic acid, and heated over a 
free flame. In a short time the precipitate will collect at the bot- 
tom of the beaker* in the form of a resinous mass. The supernatant 
fluid is now poured off, and the precipitate washed twice in dis- 
tilled water. The precipitate is then covered with about 8 c.c. of 
distilled water and treated with 0.5 c.c. of a sodium hydrate solu- 
tion of a specific gravity of 1.16. The solution will assume a dark- 
blue color, and is heated until it turns a grayish-yellow. A small 
portion is then poured into a test-tube, allowed to cool and a few 
drops of dilute copper sulphate solution added. In the presence 
of albnmose, the solution will now turn red (biuret test). If 
urobilin is present, a positive reaction may be obtained in the 
absence of peptone, hence the urine should first be treated with 
lead acetate, or only small quantities, such as 10 c.c, of urine 
employed. 

A simple way of detecting albumoses is to acidify the urine 
strongly with acetic acid, and then to add an equal volume of 
saturated solution of common salt. If albumoses are present, a 
precipitate occurs, which dissolves on boiling and reappears on 
cooling. In the presence of serum-albumin, the boiling fluid 
should be filtered. 

Albnmose may still further be demonstrated by adding sodium 
hydrate and very dilute copper sulphate to the filtrate, when a pink 
color will appear (biuret reaction), or by boiling it with Millous 
reagent (red color). 

. A very satisfactory test, which does not react with moderate 
amount of urobilin, is that of Bang. 1 Ten c.c. of the suspected 
urine are boiled with 8 grammes of powdered ammonium sulphate. 
The fluid is then centrifuged, the supernatant fluid poured off and 
the sediment stirred with alcohol in an agate mortar. After the 
alcohol is poured off, the sediment is boiled with a little water and 
treated with sodium hydrate and copper sulphate, as before. 

Peptone. — Three hundred c.c. of urine are saturated with 
amnioi limn sulphate at 60-70° C, filtered on cooling, rendered 
alkaline with sodium carbonate, again saturated between 60° and 
70° C, filtered, neutralized with dilute acetic acid and saturated 
a third time between 40° and 50° C, cooled and filtered. The 
filtrate is diluted with an equal amount of distilled water, and 
'Dentseh. inert. Woch.. 180S. p. 17. 



TESTS FOR ABNORMAL CONSTITUENTS: gj 

treated, drop by drop, with a fresh solution of tannic acid. ; The, 
precipitate is filtered off the following day, dried, powdered and 
covered with a small amount of baryta water, containing an exoess 
of baryta. After heating on a water-bath for two or three minutes; 
the mixture is set aside one to two hours, and then filtered. A 
positive biuret test will finally indicate the presence of true 
peptone. 

Bence Jones Bodies. — A urine containing Benco Jones albu- 
nmse will show the following reactions : 1. If the filtered urine be 
heated up to 5f>°-G0° C, a turbidity will form, which disappears 
at 80°-85° C, but reappears as a fbcculent precipitate on cooling. 
2. With Heller's ring test, a white ring will form at the line of 
junction of urine and acid. On heating, this disappears, but also 
reappears as a floceulent precipitate on cooling. 3. A more or less 
distinct biuret reaction can be obtained. 4. The addition of 33 
per cent, acetic acid at ordinary temperature causes no turbidity, 
not even if considerable acid is employed and the urine boiled. 
5. On standing for some time, fatty crystals, the so-called spheroids 
of Xaunyn, will separate out. The proteid is furthermore precipi- 
tated by sodium chloride in an acid urine before complete satura- 
tion, and will give the xantho proteic and other color reactions for 
albumin as a class. Tor a number of other reactions, of interest 
only to the physiological chemist, the reader is referred to the 
article by Joehniann and Schumm. 1 

Nucleo-albumin. — The test for nucleo-albumin given in most 
works is the following: A test-tube two-thirds full of urine is 
treated with about 10-20 drops of a 50 per cent, solution of acetic 
acid and set aside. After a few minutes the test-tube is compared 
with another one containing urine not treated with acid, when a 
distinct opalescence will be observed. It has been shown, how- 
ever, that this is not due to nucleo-albumin, but to a fibrinogen and 
euglobulin. With the exception of the crude nitric acid test, there 
is as yet no simple method of detecting nucleo-albumin. The 
complicated tests necessary depend upon the presence of phos- 
phorus in the molecule. 

A considerable quantity of urine — about 100 c.c. — is acidulated 
with acetic acid, and the precipitate filtered off, washed in water 
and rubbed tip in a mortar with a little sodium carbonate solution. 
If the precipitate does not dissolve entirely, it may be necessary 
to add a little sodium hydrate. The phosphates are removed by 
filtering, re-precipitating and washing with water. The final 

1 Zeitsch. f. klin. Med., vol. 46, p. 445. 



82 EXAMINATION OF URINE. 

precipitate is divided into two portions. One is shaken up with 
25 c.c, of 33 per cent, hydrochloric acid, the mixture boiled gently 
for ten minutes, allowed to cool, rendered alkaline with sodium 
hydrate and a few drops of copper sulphate (dilute) added. After 
boiling, cooling and allowing to settle, mucin, if present, will give 
rise to a red deposit of copper oxide. The other portion is rubbed 
up with a little alcohol and boiled on a water-bath. The precipi- 
tate is filtered off, washed with alcohol, shaken up with ether, 
allowed to stand for a while, filtered, dried and then fused with 
thirty parts of a mixture of sodium carbonate one part, potassium 
nitrate three parts. The fused mass is dissolved in nitric acid and 
boiled, then about 5 c.c. of a solution of ammonium molybdate 
(10 per cent.) are added. A yellow precipitate indicates the 
presence of phosphorus, which could only come from nucleo 
albumin. 

Fibrin.— The clots of suspected fibrin should be collected, 
washed and dissolved in a 1 per cent, solution of soda or a 5 per 
cent, solution of hydrochloric acid. On cooling, the solution is 
tested as for serum albumin. 

Histon.— Albumin, if present, is removed. The urine is then 
precipitated with alcohol, and the precipitate dissolved in boiling 
water. On cooling, hydrochloric acid is added, and the urine 
allowed to stand several hours, when any cloudiness is filtered off 
and the filtrate precipitated with ammonia. The precipitate is 
washed with dilute ammonia and dissolved in dilute acetic acid. 
If the biuret test is positive and coagulation occurs on heating, 
histon is present. 

Quantitative Test of Globulin, etc. — While the use of Esbach's 
albuminometer will give a rough idea of the amount of albumin 
present in urine, it will not tell what kind of albumin is 
being dealt with. Oswald 1 has very recently modified the 
test in the following way: Four albuminometers are taken, 
and each filled up to the mark TJ with urine from a burette, the 
amount of urine necessary being noted. Tube A is filled in the 
usual manner up to R with Esbach's reagent, and the total amount 
of albumin determined. In the other tubes the different forms of 
albumin are precipitated with various amounts of concentrated 
solution of ammonium sulphate. Thus tube B received 2.8 c.c. to 
7.2 c.c. of urine, corresponding to a saturation of 28 per cent. ; 
tube O, 3.6 c.c. to 6.4 c.c, corresponding to a saturation of 36 per 
cent., and tube D, 5 c.c. to 5 c.c, corresponding to a saturation of 

1 Miinch. med. Woch, Aug. 23, 1904. 



TESTS FOB ABNORMAL CONSTITUENTS. 83 

50 per cent. Each albuminometer may be marked with a glass 
pencil, so that accurate measurement is not necessary in subsequent 
cases. After twenty-four hours each precipitate (except that in 
tube A) is collected on a small filter, dissolved in water with the 
addition of a little sodium carbonate, diluted up to the mark U in 
an albuminometer, and then re-precipitated with Esbach's solution 
up to the mark E. The following results will be obtained : 

Albuminometer B will contain fibrinogen and fibrinoglobulin. 
Precipitate albuminometer C minus that of B = euglobulin. 
Precipitate albuminometer D minus that of C = pseudoglo- 

bulin. 
Precipitate albuminometer A minus that of D = total albumin. 

The following are the results of a number of cases examined by 
the author of this method : 

A B C-B DC A-D 

Total Pseudo- Serum 

Albumin Fibrinogen Euglobulin globulin Albumin 

0/ 0/ 0/ 0/ 0/ 

. t /oo /oo /oo /oo /oo 

Acute scarlatinal nephritis. .. 10 2.5 1.5 6 

Acute advanced nephritis 12 0.5 11.5 

Acute nephritis 5 0.25 1.25 3.5 

Chronic nephritis (1) 4 trace 1 3 

Chronic nephritis (2) 8 trace 2 6 

Where only traces are present, it may be advisable to use specially- 
constructed Esbach tubes, with very narrow bottom. 

Sugar. — Since the evening sample often contains sugar and the 
morning sample not, both should be examined ; and in quantitative 
work, a sample of the entire amount of twenty-four hours. Since 
moderate degrees of glycosuria disappear with strict diet, the 
patient should be instructed to take some carbohydrate on the day 
before. 

Life insurance examiners have been frequently misled by 
patients who have been previously instructed by their family phy- 
sician to carefully avoid starch and sugar for a certain time before 
presenting themselves for examination. The urine must be sent 
as fresh as possible, as it often contains yeast, which tends to 
decompose traces of sugar. In every case albumin should first be 
removed by boiling and filtering, unless present in mere trace. 

But few of the sugar tests are absolutely conclusive in the posi- 
tive sense, and cases are wrongly pronounced diabetic every day 
because the careless examiner has failed to confirm a doubtful reac- 
tion with one or more other tests. There is only one specific 
reaction for sugar, and that is its property to ferment in the pres- 
ence of yeast. 

1. Nylanders Test. — The simplest, most convenient, and at 
the same time one of the most accurate, tests for detecting the 



8& EXAMINATION OF URINE. 

presence of glucose in urine is by means of Xylander's reagent 
■(jRochelle salts 1 grammes, bismuth subnitrate 2 grammes, and 
sodium hydrate 10 grammes, are dissolved in 90 c.c. of water, 
heated to the boiling point and filtered on cooling. Should be kept 
in a dark bottle). To a few cubic centimeters of urine in a test- 
tube about one-tenth of the amount of reagent is added, and the 
mixture then boiled briskly over the Bunsen name. Jn the pres- 
ence of sugar the mixture will turn black at once, or soon after 
boiling, owing to the reduction of the dissolved bismuth to sub- 
oxide of bismuth. With mere traces of glucose, the fluid will 
merely turn brown, but will appear black with transmitted light. 
Reduction after cooling is of no significance. Urines free from 
sugar are not altered, or else will throw down a white precipitate, 
consisting of phosphates. 

The test is absolutely conclusive only in a negative sense, since 
there are many substances other than sugar which will cause par- 
tial or complete reduction (pigmentary bodies, chiefly uroerythrin,. 
hematoporphyrin, indoxyl-glycuronic acid, ammonium carbonate, 
hydrogen sulphide, mucin and albumin). In the presence of O.fi 
per cent, albumin a red precipitate will be produced, while 1-2 per 
cent, causes a black sediment, not unlike that due to sugar. 

A number of drugs will also cause ready reduction. Among 
these are rhubarb, senna, kairin, tincture of eucalyptus, oil of tur- 
pentine, quinine, antipyrine, acetanilicl, arsenic, salicylic acid 
compounds, sulphur, mercurials, santonin, tannic acid, chloralhy- 
drate, benzol, sulphonal, trional, sodium benzoate, large doses of 
creosote and podophyllo-toxin. 

These foreign bodies can, however, be removed to some extent by 
first precipitating the urine with acetate of lead, or by acidifying 
with acetic acid, boiling and filtering, in case of albumin. Ln 
doubtful cases the polariscope or fermentation test should always 
be used as control. Care should be exercised in boiling urines 
containing an excess of mucin, since the alkali in the reagent ren- 
ders this stringy, and the mixture is liable to splutter. 

Recently a stronger. rSTylander's solution has been recommended 
(containing about 8 per cent, bismuth). It works more rapidly, 
but is more apt to react with bodies other than glucose. 

2. Briicl-e's Test. — Briicke uses the following reagent: 1.5 
grammes of freshly-precipitated bismuth subnitrate are heated to 
boiling with 20 c.c. distilled water; 7 grammes of potassium iodide 
are then dissolved in the mixture, which will turn red. Finally, 
1.5 grammes of hydrochloric acid are added. Two test-tubes are 



TESTS FOR ABNORMAL CONSTITUENTS, 85 

filled to the same height, one with water and the other with the 
urine to be examined. Sufficient hydrochloric acid is added to the 
water, so that a drop of the reagent no longer causes a precipitate, 
and the same amount of acid is then added to the urine. This is 
followed by the reagent until precipitation is complete, after which 
the whole is filtered. The filtrate should show no turbidity upon 
adding reagent or acid. An excess of potassium or sodium hydrate 
is then added, and the mixture treated as in Xylander's test. 

This test is rarely employed. It also reacts with the glycuronic 
acid compounds and with pigments, but the presence of albumin 
is not a disturbing factor. 

3. Maschhe's Test. — The albumin .is here removed by adding 
three or four times the amount of a solution consisting of sodium 
tnngstate 30 parts, 30 per cent, acetic acid 75 parts, distilled water. 
120 parte. The urine is then filtered and treated with a few drops 
of reagent. If no precipitation occurs, half the volume of con- 
centrated sodium hydrate and a pinch of bismuth subnitrate. are 
added, and the mixture heated. A black precipitate will indicate 
sugar, but if only a brownish discoloration appears, or a black pre- 
cipitate on prolonged boiling, only physiological traces are present. 

Sources of error are pigments, glycuronic acid and hydrogen 
sulphide. 

4. Folding's Solution. — This consists of equal parts of a cop- 
per and an alkaline solution. The copper solution consists of 
copper sulphate 34-. 639 grammes in 500 c.c. of water (approxi- 
mately 1 ounce to the pint) ; the alkaline solution of 173 grammes 
Rochelle salts and 125 grammes of potassium hydrate in 500 c.c. 
of water (approximately 6 ounces and 1 ounces to 1 pint). These 
should be mixed fresh and boiled, after which a small amount of 
urine is added, and the mixture then heated short of boiling. In 
the presence of sugar, the fluid will first become opaque, then yel- 
low and red, and after standing a red precipitate is thrown down. 
Mere turbidity, with green or yellowish discoloration, is of no 
significance. 

This test is open to the same objections as Xylander's, since a 
number of foreign substances may occur in the urine, which give a 
partial reduction and leave one in doubt as to whether traces of 
glucose are present. 

It is generally stated that there are two classes of bodies which 
interfere with the reaction : those which, in addition to glucose, 
cause copper reduction, and those which will prevent the reduction. 

The former include the urates and purin bases, kreatinin, 



Ob EXAMINATION OF URINE. 

indican, alkapton, hippuric acid, nucleo-aibumin, urinary pig- 
ments, glycuronic acid, pyrocatechin, hydrochinon, other sugars, 
alkaloids, arsenic, tannic and gallic acid, pyrogallol, camphor, 
copaiba, cubebs, chrysophanic acid, salicylates, oxalic acid, chloral, 
turpentine, glycerine, sulphonal, thallin, benzoic and carbolic acid. 
The reduction caused by these substances is never, however, as com- 
plete as with glucose; that is, precipitation occurs only on boiling 
or when cooled off, and bv mere heating; short of boiling; onlv a dis- 
coloration occurs. 

Substances which retard the reaction, even if glucose is present, 
are albumin and some of its products, salts of ammonia and 
saccharin. 

5. Trommer s Test. — This depends also upon the reduction of 
copper sulphate to cuprous oxide. 

A few c.c. of urine are rendered alkaline by one-third the 
amount of 10 per cent, potash or soda lye, and then treated, drop 
by drop, with a 10 per cent, solution of copper sulphate, until the 
cupric oxide formed is no longer dissolved. On boiling, a yel- 
lowish precipitate of cuprous hydroxide is formed, which will 
gradually settle as the red cuprous oxide. 

This test is open to the same objections as Fehling's. It is also 
more reliable if the heating is interrupted short of boiling, but 
then faint traces of glucose often escape detection. 

Fehling's and Trommer's tests have been modified in a number 
of ways to avoid error. Dilution of the urine is a very valuable 
procedure, unless mere traces of glucose are present, when. these, 
too, will escape detection. Johnson removes all the reducing sub- 
stances by adding to the urine one-twentieth its volume of saturated 
sodium acetate and one-fortieth its volume of saturated corrosive 
sublimate. After forty-eight hours the precipitate is filtered off. 
The excess of mercury is then removed by hydrogen sulphide, and 
the latter removed by boiling. 

Repeated filtration through animal charcoal will also remove a 
large percentage of reducing substances. It was formerly believed 
that some glucose is also filtered out by this procedure, but Budisch 
has shown that this amount is so slight as not to interfere with the 
quantitative estimation. The charcoal should be animal, and free 
from impurities. After repeated filtration, the urine will flow 
through almost colorless, yet occasionally may reduce copper, even 
where sugar is absent. 

Worm-Muller's modification depends on the fact that at a tem- 
perature below 70° C. reducing substances other than glucose 
react only to a slight degree, or not at all. 



TESTS FOR ABNORMAL CONSTITUENTS. 87 

The reagent is prepared by dissolving 10 grammes of Eochelle 
salts in a 4 per cent, solution of sodium hydrate; 2.5 c.c. of this 
solution are heated with 1 c.e. of a 2.5 per cent, solution of copper 
sulphate just short of boiling. Five c.c. of the urine to be 
examined, freed of albumin, are heated to the same degree at the 
same time. Ten to twenty-five seconds are allowed to escape, after 
which the urine is added in small portions to the reagent. If 
glucose is present, red cuprous oxide will soon separate out. If 
the reaction does not occur, the test should be repeated, with in- 
creased amounts of copper sulphate solution, until 4.5 c.c. are 
utilized for one test. 

Among other modifications, Haines' and Elliott's possess the 
advantage that only very small amounts (8 drops) of urine are 
necessary. Haines uses a reagent consisting of copper sulphate 2 
grammes, glycerine 15 grammes, liquor potassse 150 c.c, water to 
make 200 c.c. Half a test-tube of the solution is heated to boiling 
first alone, and then with 6-8 drops of urine. 

Pavy's method is similar to Rudisch's for quantitative work. 
Owing to the presence of ammonia, the precipitate remains dis- 
solved, and the blue solution simply becomes colorless. It is open 
to the same objections as the other methods. 

6. Moore s Test. — If urine containing glucose is boiled with 
one-third its amount of 10 per cent, potash or soda lye, it will turn 
dark brown or intensely brownish-yellow. Dilute urine will give 
a pure yellow color. 

This test is fairly delicate, but has been replaced by those al- 
ready mentioned, since less reliable. It also reacts with mucin, 
proteids, biliary pigments and alkapton. These may be removed 
to some extent by boiling and filtering through charcoal. 

7. Buhner s Test. — Ten c.c. of urine are treated with an equal 
amount of saturated solution of acetate of lead and filtered. 
Ammonia is then added, drop by drop, to the filtrate, until the 
precipitate no longer dissolves. On heating up to 88° C. in the 
water-bath, the precipitate will turn pink. This test is too com- 
plicated for routine work, though delicate and reliable. 

Stem thinks very highly of it, and states that, when properly 
performed, only certain glycuronic acid compounds may give rise 
to error. He has modified the test as follows : Take from 1-5 c.c. 
of urine and add to it an equal amount of ammonia hydrate, then 
add about 5 drops of strong solution of lead acetate. A white, 
flocculent precipitate, composed of sulphate, phosphate and 
chloride of lead and hydrated lead oxide, will appear immediately. 



B8 EXAMINATION OF URINE. 

Heat gently a part of the sediment over an alcohol lamp until two 
or three bubbles rise to the surface. If 'glucose is present, there 
will appear in the heated region of the sediment a well-defined, 
pink spot, the intensity of which, is dependent oil the amount of 
glucose present. With less than 0.1 per cent, glucose, the spot 
will appear yellowish. It is best to conduct the test in test-tubes 
of the smallest calibre, which have been previously well cleaned. 
Urines of a specific gravity higher than 1,010 should be diluted 
before the test is applied. 

S. Heating Test. — Where no reagents are at hand, a small 
quantity of suspicious urine may be evaporated to dryness in a 
porcelain or other available dish. If the heating is continued, the 
residue will become brown and sticky in the presence of sugar, and 
an -odor of caramel will be emitted. 

9. Methylene Blue Test. — Frolich recommends the following 
procedure : Ten c.c. of urine are treated w T ith 5 c.c. of concen- 
trated solution of neutral lead acetate and the same amount of con- 
centrated solution of basic lead acetate, and filtered through a dry 
filter. Some of the filtrate is placed into a test-tube ;• into another 
an equal amount of 1-300 aqueous solution of methylene blue. The 
latter is rendered alkaline with one-fifth its amount of 10 per cent, 
solution of potassium hydrate and warmed. JSTow the filtered urine 
is added, and the fluid heated to boiling. In the presence of 
dextrose the bluish-black mixture will turn lighter, and finally 
become yellowish and transparent. The decolorization occurs 
almost always within twenty or twenty -five seconds after boiling. 
The decolorized fluid will again turn bluish on shaking, but this 
will disappear on standing. 

The great drawback of the method lies in the fact that every 
normal urine will possess reducing properties corresponding to 0.1 
per cent, glucose. Levulose and kreatinin may also interfere. 

10. Pierre Acid Test. — If saccharine urine is heated with an 
equal bulk of saturated solution of picric acid and some potassium 
or sodium lye, a dark cherry coloration will result, owing to the 
formation of picramic acid. The source of error is, however, 
great, since even normal urine will show the reaction to a slight 
extent, owing to the presence of glucuronic acid. Other substances 
which interfere are uric acid, kreatin, kreatinin, acetone and pig- 
ments. 

11. Sodium Sulplio-indigotate Test. — If a solution of indigotin- 
disulphonic acid is saturated with sodium carbonate and boiled 
with a solution containing sugar, it will turn green, purple, red and 



TESTS FOR ABNORMAL CONSTITUENTS. 89 

yellow. On shaking the still warm solution, it will again change 
color in the reverse order. A number of other substances also give 
the reaction, especially glycuronic acid, inosite, lactose, gallic, 
tannic and salicylic acid and their compounds. 

12. Hoppe-Seylers Test. — To 5 c.c. of a 0.5 per cent, solution 
of orthonitro phenylpropiolic acid in caustic soda and water, 10 
drops of the urine to be tested are added, and the mixture then 
boiled half a minute. If the solution turns dark blue, at least 0.5 
per cent, sugar is present. Though not very delicate, the test 
seems to be fairly reliable, since only lactose and indoxyl cause the 
same reaction. 

13. Penzoldtfs Test. — If to urine rendered alkaline, paradiazo- 
feenzolsulphonic acid is added, a red coloration, turning to violet 
in ten to fifteen minutes, will be observed. In proper dilution, the 
mixture will show an absorption band between D and F, and 
another one at G. The reagent is difficult to handle, since 
explosive, and also reacts with albumin, acetone, phenol and 
pyrocateehin. 

11. Furfural Test. — If 1 c.c. of concentrated sulphuric acid is 
allowed to run beneath 0.5 c.c. of a dilute sugar solution, contain- 
ing one drop of a 15 per cent, alpha naphthol solution, a green 
ring will form at the surface of contact, which is soon followed by 
a dark violet rinff above this. If the mixture be shaken, it will 
turn cherry red, with a bluish hue. With the spectroscope a nar- 
row band may be detected between D and E, to be followed by a 
band beginning at F and extending to the violet end. The reaction 
is due to the formation of furfurol by the action of sulphuric acid 
on sugar. Instead of alpha naphthol, thymol or xylidin may be 
used. The latter may be employed in the form of test-paper, as 
follows : Strips of paper are saturated in a mixture composed of 
equal volumes of xylidin and glacial acetic acid, to which some 
alcohol has been added. If the dried paper is held over saccharine 
urine heated with sulphuric acid, furfurol will be given off and 
will color it red. Other substances which react like sugar are 
other sugars, glycosides, albumin and peptone. 

15. Horsley-Pratesi s Test. — 2.5 grammes potassium hydrate 
are dissolved in 60 grammes of a very strong solution of potassium 
silicate (water glass), to which 2 grammes of potassium bichromate 
are added. A drop of the reagent is then placed on a small strip 
of tin and dried by holding over the flame. Four drops of the 
reagent are evaporated on the same spot. A drop of the suspected 
urine is then allowed to come in contact with the evaporated 



90 



EXAMINATION OF URINE. 



reagent and heated. A green color will appear in the presence of 
sugar, but albumin, glucuronic acid and pigments will give the 
same reaction. 

16. Fermentation Test. — Any fluid containing glucose will' 
readily ferment in the presence of yeast. Since the glucose will 
split up into alcohol and carbon-dioxide, its presence will manifest 
itself by the formation of gas. The cheapest and most suitable 
apparatus is the Einhorn fermentation tube, but certain precau- 
tions are necessary in its use. The urine should not be shaken 
with the yeast, since a certain amount of air will be entangled;, 

Fig. 25. 




Einhorn's sacchari meter 



which will slowly rise after the mixture is poured into the tube. 
It is best to let the urine stand a few minutes after the yeast has 
been added, and then to distribute the latter gently with a glass 
rod before pouring into the tube. In addition, the tube may be 
inclined on a suitable clamp before setting aside. Fermentation is 
more active in a warm place, so that the tube is best placed in the 
incubator or near a stove during cold weather. At the end of 
twelve hours fermentation will be nearly complete, and a small or 
large volume of gas in the long arm will establish the presence of 
glucose in all doubtful cases. When there is some doubt as to the 
nature of the ^as, the tube may be inverted under water, so that the 



TESTS FOR ABNORMAL CONSTITUENTS. 



91 



gas can escape into a test-tube filled with lime-water, which will 
not be affected by air, but will turn turbid in case of carbon- 
dioxide. Since some yeast is self-fermenting, it is often advisable 
to make a control test with urine free from sugar or with water. 
When the Einhorn fermentation tubes cannot be procured, the 
mixture of urine and yeast may be poured into a test-tube, which 
is then inverted into a vessel containing mercury. 

The fermentation test is the only absolutely certain test for 
sugar, since nothing but sugar will react with yeast. There may, 
however, be some doubt as to the kind of sugar, since maltose and 
other carbohydrates will also yield carbon-dioxide. These, how- 

Fig. 26. 




*oleil-Ventzke : s saechari meter. 



ever, occur so rarely that they may be practically disregarded. 
Occasionally a lirine containing appreciable amounts of sugar will 
not ferment, since some preservative has been added or since the 
patient has taken antifermentative drugs, which have passed into 
the urine. 

IT. Polariscope. — The simplest way of detecting the presence 
of sugar in urine is by means of the polariscope. Since albumin 
is levuloratatory, it must first be removed by acidifying slightly 
with acetic acid, boiling and filtering. If the urine is not abso- 
lutely clear, and if too highly colored, lead acetate in substance or 
solution should be added, as the resulting precipitate will carry 
down the suspended matter and the pigments. The resulting pale 



92 EXAMINATION OF URINE. 

fluid is filled into the glass tube, then placed in the instrument. 
The readings are best taken in a dark room, with sodium or strong 
electrical light. 

Certain precautions are necessary. Thus, the tube must be 
absolutely clean and dry, and in filling, bubbles of air should be 
avoided. Every normal urine turns the plane of polarized light to 
the left (0.1 — 0.3 per cent.), hence for the detection of traces of 
sugar two polarimetric readings are necessary, one before fermen- 
tation and another after. Diabetic urine frequently contains 
(3 -oxybutyric acid, which also turns to the left; its presence is ren- 
dered probable by the detection of acetone and diacetic acid. Here, 
also, two readings are necessary. 

Conducted with a delicate instrument, polariscopy is a very 
reliable means of detecting sugar in urine. It must be remem- 
bered, however, that dextrorotation, unlike fermentation, is not 
specific for glucose. Glycuronic acid may be present, or the inges- 
tion of certain drugs (morphine, etc.) may also cause a rotation to 
the right. Then, also, the presence of levulorotatory substances, 
such as albumin, levnloso, /^-oxybutyric acid, cystin and certain 
drugs, may neutralize the dextrorotation and lead one to believe 
that no sugar is present. 

18. Phenylhydrazine Test. — Five c.c. of urine are treated with 
0.5 gramme phenylhydrazine hydrochlorate and twice the amount 
of sodium acetate. The test-tube containing the mixture is placed 
in a water-bath and heated for half an hour, then chilled by 
immersing in a beaker with cold water. Characteristic, needle- 
shaped crystals will adhere to the sides and bottom of -the test-tube, 
and can be readily identified bv microscopical examination. 
(Plate III.) 

Eiegler 1 has modified the phenylhydrazine test as follows : One 
c.c. of urine is treated with a pinch of phenylhydrazine oxalate 
and 10 c.c. of water. After boiling, 10 c.c. of a 10 per cent, solu- 
tion of caustic potash are added, and the test-tube shaken thor- 
oughly, when a beautiful reddish-violet color will appear within 
one minute in the presence of at least 0.05 per cent, glucose. 
Havelburg recommends that 1.2 grammes phenylhydrazine hydro- 
chlorate and 1.8 grammes sodium acetate be warmed with 10 c.c. 
of distilled water. Ten c.c. of the suspected urine are then added ; 
with 8-15 drops of chloroform. The chloroform will soon fall to 
the bottom, and if sugar is present a fluid layer will be found above 
it, in which the characteristic crystals are contained. 
^Deiitsch. med. Woch., April 9, 1904. 



PLATE III 




Phenylgluecsazon Crystals obtained from a Diabetic 
Urine. (Simon. 



TESTS FOR ABNORMAL CONSTITUENTS. 93 

Substances besides glucose which form crystals of osazone are 
levulose, maltose and pentose. These can only be distinguished by 
their different melting point, solubility and optical behavior. 

Summary. — A rather full list of sugar tests has been given, 
since almost all are open to some objection and have some defect, 
so that there may be occasion to employ several to confirm a diag- 
nosis of diabetes. Those most commonly employed are Xy lander's, 
Folding's and the fermentation test. The most reliable are Rub 
ner's, the fermentation and polariscope test, while. the others are 
only rarely resorted to. 

The following table gives an idea of the delicacy of the various 
tests: 

Per Cent 

Nylander's test 0.1 

Briicke's test \ ._ 0.2 

Maschke's tot 0.2 

Fehling's test 0.3 

Trommer's test 0.1 

Filtration through charcoal 0.01 

Worm — Miiller's test 0.25 

Haine*s test 0.2 

Elliott's test 0.2 

Parr's test 0.2 

Phenylhydrazine test 0.03 

Moore's test 0.5 

Rubner's test 0.1 

Methylene blue test 0.4 

Picric acid test 0.1 

Sodmm-sulphoindigotin test 0.1 

Hoppe-Seyler's test 0.5 

Penzoldt's test 0.1 

Furfurol test 0.02 

Horsley-Pratesi's test 0.4 

Fermentation test 0.1 

Polarization 0.1 

It occasionally happens that in rare cases it is necessary to 
separate the glucose from the urine. This is done as follows : A 
large amount of urine is evaporated to a thin syrup, then about 
half the amount of ether is added. The mixture is then allowed to 
evaporate, when, after several days, the syrup will have crystal- 
lized. The urea and extractive matter are removed by treating 
the crystals with a small amount of alcohol. The residue is then 
dissolved in boiling alcohol, the solution filtered while hot, and the 
filtrate allowed to crystallize. The separated crystals are 
repeatedly subjected to crystallization from methyl alcohol. They 
form four-sided prisms, which melt at 141-146° C. and dissolve 
slowly in water, alcohol and methyl alcohol; more readily in boil- 
ing alcohol, but not at all in ether. With large amounts of urine, 
traces of these crvstals mav be found even in normal urines. 



94 EXAMINATION OF URINE. 

Quantitative Estimation of Sugar. — 1. Fehling's Method. — 
Since 10 c.c of mixed Fehling's solution corresponds to 0.05 
glucose, an accurate quantitative analysis is possible. Ten c.c. of 
the Fehling's solution are diluted with 40 c.c. of water and boiled. 
The urine is diluted five (if specific gravity is below 1,030) or ten 
(if specific gravity is above 1,030) times, poured into a burette and 
added in small quantities to the boiling Fehling solution until all 
of this has precipitated as red cuprous oxide and the supernatant 
liquid is colorless. . The degree of dilution multiplied by 5 and 
the result divided by the number of c.c. of diluted urine employed 
will give the percentage of sugar. Owing to the fact that it is diffi- 
cult to determine the end reaction, a small portion of the Fehling's 
solution may be filtered, and then treated with acetic acid and 
ferrocyanide solution. If unreduced copper is still present, a 
brown color is obtained. More accurate results are generally 
obtained with the modification of Rudisch, 1 who uses the following 
solution: Copper sulphate, 4.78 grammes; sodium sulphite, 50 
grammes ; crystallized sodium carbonate, 80 grammes ; 10 per cent- 
water of ammonia to make 500 c.c. One c.c. will correspond to 
0.001 glucose. The urine is first decolorized with charcoal, then 
10-20 c.c. of the standard solution are placed into an Erlenmayer 
flask and diluted with 50 c.c. of water. When boiling, the urine 
is allowed to flow in from a burette until the solution is decolor- 
ized. Approximate titration may be done with a Beck's burette. 

Citron 2 heats to boiling 1 c.c. of urine with 20 c.c. of Fehling's 
solution in a dish with some water. The sediment is then filtered 
through paper with the aid of some powdered pumice stone, and 
washed with hot water. The filtrate is acidified with sulphuric 
acid until decolorized, and finally 1 gramme of potassium iodide 
and some starch solution added. On now titrating with decinor- 
mal thiosulphate of sodium, a point will be reached where the blue- 
black color turns white. A specially-constructed burette is used, 
which will indicate the percentage of sugar. 

Owing to the fact that the usual estimation by means of Feh- 
ling's solution is often difficult and inaccurate, Harvey G. Beck 3 
has quite recently recommended the following modification : A 
beaker is filled one-third with water and placed over the Bun sen 
burner. Four centrifugal tubes, graduated at 2 c.c, are filled 
accurately to the mark with standard Fehling's solution, numbered 
1, 2, 3 and 4, respectively, and transferred to the beaker. As soon 

1 Jacobi Festschrift. 

2Miinch med. Woch., Nov. 24, 1903. 

3 Medical News, Sept. 3, 1904. 



TESTS FOR ABNORMAL CONSTITUENTS. \)o 

as the water boils, the tubes are removed and placed into a tube 
holder in their proper order. By means of a pipette, graduated 
into twentieth c.c., four-twentieth c.c. of the urine to be examined 
is allowed to flow into tube ~No. 1, the other tubes each receiving 
one-twentieth more. Thus, four-twentieths are added to ~No. 1, 
five-twentieths to Xo. 2, six-twentieths to 'No. 3 and seven- 
twentieths to Eo. 4. The tubes are violently shaken, so as to mix 
thoroughly the urine and reagent, after which they are returned to 
the beaker and allowed to remain in the boiling water for three 
minutes. Red cupric oxide will be precipitated, and the color of 
the supernatant fluid can be readily determined by allowing the 
sediment to settle, or, better still, by placing the tubes in the 
centrifuge. If the fluid above the sediment is still blue in tube 
Xo. 4, four-twentieths c.c. more are added to each of the tubes, 
increasing the amount of urine respectively to eight, nine, ten and 
eleven-twentieths. These steps are repeated until complete decolori- 
zation is obtained, when the first tube in the series completely 
decolorized is chosen. Twenty divided by the number of twentieth 
e.c.'s used will then give the percentage of sugar present. To 
determine the end reaction more definitely, one-twentieth c.c. may 
be added to each tube after sedimentation in such a manner as to 
form a thin layer on the surface, after which the tubes are returned 
to the beaker without agitation, when a yellow ring of cuprous 
oxide will form in those tubes where reduction is incomplete. The 
advantages claimed by the author are : ( 1 ) With a little practice 
the estimation can be completed in less than ten minutes. ( 2 ) With 
reasonable care, the results are much more accurate. (3) By 
means of the number of tubes, several can be used for control tests, 
thus one can make two or more determinations at the same time. 
(4) The solution never reaches the boiling-point, and such bodies 
as uric acid, kreatin, kreatinin, nucleo-albumin, etc., will be less 
liable to reduce the Fehling's solution. (5) The delicacy of the 
test is not impaired by removing some of the solution in order to 
determine the end reaction. (6) If too much urine is added to 
one tube, the estimation can be carried out in the other tubes, 
thereby obviating the necessity of repeating the whole process. 

We have had no practical experience with Beck's method, but it 
seems that considerable difficulty will be experienced in accurately 
dropping so small a quantity as four-twentieths c.c. into the tubes. 
It would be easier and more accurate to dilute the urine two or 
three times, and to use a burette in place of the pipette. 

2. Knapp's Method is based upon the fact that mercury 



96 



EXMMINATIOJSf OF URINE, 



cyanide in alkaline solution is converted into metallic mercury in 
the presence of sugar. The solution employed consists of 10 
grammes of chemically-pure mercury cyanide. and 100 c.c. sodium 
hydrate solution, specific gravity 1.145, to the litre (20 c.c. = 0.05 
gramme glucose). Twenty c.c. of this solution are diluted with 
water to make 100 c.c. The solution is then heated to boiling, and 
urine, diluted as in Fehling's method, is added until the solution 
clears and the mercury settles to the bottom. After each addition 
the mercury is boiled. The end reaction is determined by placing 
a drop of the solution on filter paper and holding it first over a 



Fig. 27. 




Lohustein's saccharimeter. 

bottle of concentrated hydrochloric acid and then over one contain- 
ing a* saturated solution of hydrogen sulphide. A yellow spot 
should no longer appear. In the final calculation the number of 
c.c.'s of urine required divided into 5 equals the percentage of 
sugar present. 

3. Differential Density Method. — The specific gravity of the 
urine is taken carefully, then some yeast is added, and after 
twenty-four to forty-eight hours the specific gravity is taken a 
second time. The difference between the two multiplied by 230 



TESTS FOH ABNORMAL CONSTITUENTS. 97 

will then give the percentage of sugar. Stern lias constructed a 
special uringlucosometer based upon this method. It requires one 
to two days before a positive result can be obtained, is very in- 
accurate and can hardly be recommended for ordinary use. 

4. Fermentation Test. — The Einhorn tubes are generally 
employed, but since they are graduated very poorly, and one can- 
nut tell when fermentation is completed, they should be discarded 
in favor of the more accurate Lohnstein saeeharometer. This is 
essentially a U-shaped tube, open at both ends. The longer limb 
is closed during the process of fermentation by a ground-glass 
stopper. This stopper, is provided with an air-hole, to which a 
similar hole corresponds in the drawn-out portion of the tube. The 
apparatus is filled with the urine, mixed with yeast, through the 
bulb A, while the two air-holes at B are in communication. The 
level of. urine shonld.be exactly at the zero mark. The stopper is 
then turned so that all communication is shut off, a little mercury 
is finally poured into the instrument and the whole placed into a 
jressel containing water at 35° to 40°, or into an incubator. After 
twelve hours fermentation will be complete, and the percentage of 
sugar can be read off. A test-tube accompanies the instrument, 
which enables accurate dilution. Sufficient water should always 
be added to the urine, so that the resulting mixture does not con- 
tain more than 1 per cent, sugar. 

• 5. Polariscopic Test. — The use of the polariscope, as described 
on a previous page, is the quickest and most convenient way of 
estimating the percentage of sugar. Unfortunately, the instru- 
ment is too expensive for general use. If very accurate results are 
desired, the urine should be polariscoped twice, once before and 
once after fermentation, and the amount of levulorotation then 
added to the dextrorotation. Where acetone and diacetic acid are 
present, there is probably also some /3-oxybutyric acid, which is 
decidedly levulorotatory, hence a double determination is abso- 
lutely necessary here. 

Lactose.— Lactose gives a positive Trommer's and Xylan der's 
test, but phenylhydrazine does not give an osazon, and fermenta- 
tion does not begin until about twenty hours have elapsed. 

A special reaction for milk-sugar is that of Ivubner. The urine 
is boiled two or three minutes with an excess of lead acetate. If 
lactose is present, the urine turns yellowish-brown, and the- precipi- 
tate dissolves in ammonia with a brick-red color. On standing, a- 
cherry-red or copper-colored sediment falls to the bottom, while 
the supernatant liquid becomes clear and colorless. Dextrose will 



98 EXAMINATION OF URINE. 

give the same reaction, hence it should first be removed by fermen- 
tation. 

Levulose. — Levulose reduces the solutions commonly employed 
and ferments, but turns the plane of polarized light to the left. 
For its detection SeliwanofFs test is used: 10 c.c. of urine are 
heated with resorcine and 2 c.c. of dilute muriatic acid, when a red 
color will appear. 

Maltose. — Maltose behaves very much like glucose, but the crys- 
tals obtained on treating with phenylhydrazine have a different 
melting-point (207° C). 

Laiose (Leo's Sugar 1 ). — On titrating a urine containing laoise, 
.1.2 to 1.8 per cent, more sugar will be indicated than by the 
polarimetric method. It is not as sweet as dextrose, does not fer- 
ment as actively and forms a well-characterized compound with 
phenylhydrazine. It does not give the Seliwanoff reaction. 

Pentose. — Pentose is recognized by the following reaction: 
Three c.c. of urine are heated to boiling with 3 c.c. of hydrochloric 
acid (specific gravity 1.19) and a pinch of phloroglucin, when a 
cherry-red color will appear, which soon changes to greenish-black. 
Amyl alcohol will take up the pigment, and on spectroscoping the 
solution a band of absorption will appear between yellow and 
green. Instead of the above, Bial's reagent may be employed 
(Orcin 0.5, liquor ferri sesquichlorate 10 drops, acid muriatic con- 
centrated 250 c.c). A bluish-green pigment will separate out on 
boiling, which is also soluble in amyl alcohol. 

Glycuronic acids also give the pentose reaction; the phloroglucin 
more readily than the orcin. In order to remove these, it is neces- 
sary to benzoylate 500 c.c. of urine, saponify the resulting ester 
with sodium ethylate and filter. A positive reaction in the filtrate 
can then only be due to pentose (v. Ahlftan). 

Glycuronic Acids.- — Glycuronic acid as such gives the pentose 
reaction, but since usually combined in the urine, slight differ- 
ences in color are noted. Thus, with phloroglucin a more brown 
coloration is obtained, but the same band of absorption as pentose. 
The orcin reaction is only positive in case of menthol and turpen- 
tine-glycuronic acid, but the precipitate is violet instead of 
greenish-blue, unless spontaneous decomposition has set in and the 
acid is liberated. In a general way, glycuronic acid can be recog- 
nized by the history of the case and the odor of the urine. Thus, 
the patient may have taken chloral, camphor, naphthol, phenol, 
morphine, antipyrine, etc. ; or an odor of peppermint may suggest 
1 See Virchow's Arch., vol. 107, p. 108. 



TESTS FOB ABNORMAL CONSTITUENTS. 



99 



menthol, or one of violets, turpentine and allied bodies. Trom- 
mer's and Eylander's tests are usually partially or completely posi- 
tive. The plane of polarization is turned to the left, but to the 
right if the acid is set free by boiling with sulphuric acid. In this 
free state the phenylhydrazine, orcin and phloroglucine tests are 
positive, but fermentation is negative under all conditions. 



Summary. 


Trammer's 

or 

Fehling's 

React, 


Nylan- 
der's. 


Ferment. 


Phenyl- 
hydraz. 


Polarise. 


Orcin 
React. 


Special 
Test. 


Glucose 


+ 


+ 


+ 


+ 
tmelting point 

20 5 °w) 


right 


- 


- 


Levulose 


+ 


+ 


- + 


+ 

(meltine point 

205°C) 

+ 


left 


— 


Seliwanoff's 
reaction 


Maltose 


+ 


+ 


+ 


(melting- point 
2p7°C) 


right 






Lactose 


+ 


+ 


negative in 

the first 20 

hours 


- 


right 


- 


Rubner's 
reaction 


Laiose 


+ 


+ 


ferments 
slowly 


+ 


no reaction 
or toward left 


- 


- 


Pentose 


+ 


+ 




+ 

(meltine point 

154— 160 ) 


- 


+ 


- 


Glyeuronic 
Acid 






- 


only the free 
acid 


acid toward right 
salts toward left 


(after splitting 
with acid) 


- 


Alkapton 


+ 




- 


- 


- 


- 


see under 
"Alkapton" 



Acetone. — Several c.c. of urine are treated with a few drops of 
5 per cent, nitroprusside of sodium solution and strong sodium 
hydrate. In the presence of acetone, the red color will turn purple 
or violet when glacial acetic acid is added in excess. The test is 
more delicate if a large quantity of urine is distilled after the addi- 
tion of some phosphoric acid and the first 10 or 20 c.c. are 
employed. 

The following is somewhat more delicate: Several drops of 
Gram's solution and sodium hydrate are added to the distillate, 
when, in the presence of mere trace, the odor of iodoform will be 
evolved. Since this cannot always be detected readily, it is better 
to centrifuge the urine and to examine the sediment microscopic- 
ally for the characteristic crystals. 

Other tests for acetone, less commonly employed, are : 

Reynolds' Test. — A small amount of the distillate is treated 
with freshly precipitated yellow mercuric oxide, prepared by pre- 
cipitating mercuric chloride with sodium hydrate. In the presence 



t .fA 



100 EXAMINATION; OF URINE. 

of acetone, black sulphide of mercury will form in the clear, fil- 
tered solution if a few drops of ammonium sulphide are added. 

Demiiges-0 ppenhe i me r Test. — About 3 c.c. of urine are treated 
with a special reagent, drop by drop, until the precipitate formed 
no longer dissolves on stirring. The reagent is prepared as fol- 
lows : Twenty grammes of concentrated sulphuric acid are poured 
into 100 c.c. of distilled water, then 5 grammes of freshly precipi- 
tated yellow mercuric oxide are added and the mixture set aside 
for twenty-four hours. When enough of the reagent has been 
added, the precipitate is filtered off, treated with about 2 c.c. more 
and 3 to 1 c.c. of a 30 per cent, solution of sulphuric acid and 
placed in a vessel with boiling water. A slight cloud or precipi- 
tate will develop, depending on the amount of acetone present. 
Hydrochloric acid in excess will again clear up the fluid. Albumin 
will also give a precipitate, hence should be removed. The test is 
simple and delicate (1-20,000), and only possesses the disadvan- 
tage of also reacting with diacetic acid, since this yields acetone 
when treated with mineral acids. Fortunately, however, the 
significance of diacetic acid is the same as that of acetone. 

Sioch-Froliner Test. — If a small crystal of hydroxylamine 
hydrochlorate is dissolved in a few c.c. of the distillate, a blxie color 
will be obtained if this is then treated with chloride of lime solu- 
tion and extracted with ether. The test will be positive in a dilu- 
tion of 1-1,000, but will also react with diacetic acid. 

For quantitative purposes, 100 c.c. of urine are treated with 2 
c.c. of 50 per cent, acetic acid, and distilled until only one-eighth 
remains behind. The distillate is then mixed with a carefully- 
measured quantity of one-tenth normal iodine solution (12.6 
grammes iodine and 25 grammes potassium iodide to the litre). 
Usually 10 c.c. are employed for every 100 c.c. of urine. Sodium 
hydrate solution (50 per cent.) is then added in excess till all iodo- 
form has separated out. The iodine in excess is precipitated with 
concentrated hydrochloric acid and retitrated, with a decinormal 
solution of thiosulphate of soda (2-1.8 grammes to the litre), until 
the fluid assumes a pale yellow color. A few c.c. of starch solution 
are then added, and the titration continued until the last trace of 
bine has disappeared. The amount of acetone in 100 c.c, in milli- 
grams, can be determined by deducting the number of c.c. em- 
ployed in titration from the total amount of iodine added and 
multiplying by 0.976. 

Diacetic Acid. — Gerhard fs Test. — In the presence of diacetic 
acid, a few drops of ferric chloride solution will give a Burgundy 



TESTS FOR ABNORMAL CONSTITUENTS. 101 

red color. The reaction should also be positive if the urine is 
treated with sulphuric acid and shaken out with ether, and the 
test repeated with this ethereal extract. The excretion of salicylic 
acid sometimes interferes, hence the urine should first be filtered 
through animal charcoal if salol, etc., has been taken. 

Arnold's Test. — This test is, by far, the better, since it is more 
delicate, and does not respond to acetone and the various drugs. 
A 1 per cent, aqueous solution of para-amido-aceto-phenon is pre- 
pared and rendered colorless by the cautious addition of hydro- 
chloric acid. Two parts of this solution are then mixed with one 
of a 1 per cent, solution of sodium nitrite and an equal volume of 
the urine to be tested. On adding ammonia, a brownish-red color 
will appear in all urines; but in the presence of diacetic acid, ten 
to twelve times the amount of pure hydrochloric acid will give rise 
to a beautiful purple color. After the addition of the ammonia, 
Lipliawski treats 0.6-2 c.c. with 15-20 c.c. of pure hydrochloric 
acid, 3 c.c. of chloroform and 2-1 drops of an aqueous solution of 
ferric chloride. A violet tinge will result if the tube is gently 
agitated. 

y8-Oxybutyric Acid.— The presence of ^-oxybutyric acid mani- 
fests itself by a rotation toward the left after the sugar has been 
fermented with yeast. 

The quantitative test is rather complicated, and depends upon 
the conversion of ^-oxybutyria to a-crotonic acid. One hundred 
c.c. of urine are rendered feebly alkaline, and are then evapo- 
rated almost to dryness on a water-bath. The residue is transferred 
to a flask by means of 200 c.c. of 50 per cent, sulphuric acid, and 
distilled until 300 c.c. have been obtained, water being poured into 
the flask to keep up the volume. The distillate is extracted two or 
three times with ether, the ether distilled off and the residue heated 
on the sand-bath to 160° C, and dissolved on cooling with 50 c.c. 
of water. This aqneons solution of crotonic acid is now titrated 
with decinormal sodium hydrate solution, 1 c.c. of which corre- 
sponds to 0.0086 grammes of crotonic acid. By multiplying the 
result with 1.21, the amount of oxybutyria acid will be obtained. 

Hemoglobin. — If a spectroscope is at hand, the urine should be 
acidified with acetic acid, and then examined for the characteristic 
absorption bands between D and E. Upon adding ammonium snl- 
phide, reduced hemoglobin will form, which gives only one band, 
slightly beyond D. More often, however, the spectrum of 
methemoglobin will be obtained (one band between C and D, and 
another broader one between D and F). The chemical tests for 



102 EXAMINATION OF URINE. 

blood are used more often, since a good spectroscope is very expen- 
sive and the small, hand instruments are often unsatisfactory. 

Heller s Test. — The phosphates are precipitated by rendering 
the urine strongly alkaline with sodium hydrate and boiling. In 
the presence of blood, the precipitate will show a bright red color, 
and the spectrum of hemochromogen may be obtained. In the 
absence of a spectroscope, the deposit is filtered off and dissolved 
in acetic acid, when the solution remains red in the presence of 
blood, but soon turns colorless, owing to oxidation. The test is 
very delicate, since one part in 4,000 can still be detected with ease. 

Guajacum Test. — If equal parts of tincture of guajacum and 
old ozonized oil of turpentine be allowed to iloat on urine contain- 
ing blood-coloring matter in solution, a white ring will form which 
gradually turns blue. The urine should be acid in reaction. In- 
stead of turpentine, peroxide of hydrogen may be used. The test 
is very delicate, but pus will sometimes give the same ring; this 
disappears, however, on heating, while that caused by blood does 
not. 

Aloin Test. — Instead of tincture of guajacum, a 3 per cent, 
solution of aloin in 60-70 per cent, alcohol may be employed in 
the same way, mixed with oil of turpentine. A beautiful red color 
will appear at the zone of contact. 

Donogany's Test. — Ten c.c. of urine are treated with one c.c. 
of a solution of ammonium sulphide, and the same amount of 
pyridine, when an orange color will appear in the presence of 
blood. If doubt exists, the spectrum of hemochromogen should 
be looked for. If the ammonium sulphide and pyridine are not 
fresh, the color obtained will be green or brown, changing to yellow 
on the addition of ammonia, 

Melanin. — On adding ferric chloride, a black precipitate ap- 
pears in the urine in the presence of melanin, which is soluble in 
sodium carbonate and can be reprecipitated with mineral acids. 
Bromine water will also give a precipitate which rapidly becomes 
black. 

Bile Pigment. — Gram's iodine solution is diluted ten times 
with alcohol and then layered over a few c.c. of urine in a test-tube, 
when a green ring will form at the line of junction in the presence 
of bile (Smith's test). 

Instead of the above, urine may be floated over some nitric acid 
containing a trace of nitrous, made extemporaneously by heating 
pure nitric acid with a small piece of wood, until red fumes are 
given off. A play of colors will then be obtained at the zone of 



TESTS FOR ABNORMAL CONSTITUENTS. 103 

contact, of -which the green is most characteristic (Gmelins test). 
The urine may also be filtered and a drop of the acid applied to 
the filter-paper (Rosenbaeh's test). 

Hnppert precipitates 10 to 20 c.c. with milk of lime or barium 
chloride. The precipitate is filtered off and then brought into a 
beaker by perforating the filter and washing with a small amount 
of alcohol, acidulated with sulphuric acid. The mixture is boiled, 
when in the presence of bile, the solution will turn emerald-green. 
The test is very delicate, but not as easily performed as some of 
the others. 

A very delicate test has been recommended recently by A. Jolles. 1 
Ten c.c. of urine are mixed in a test-tube with 2 to 3 c.c. of chloro- 
form and 1 c.c. of a 10 per cent, solution of barium chloride. The 
mixture is then centrifuged, the fluid above the chloroform and 
precipitate poured off, and the tube filled with distilled water, 
shaken and centrifuged a second -time. In case of dark-colored 
urines, this is repeated a third time. After the water is decanted, 
the chloroform and precipitate are shaken with 5 c.c. of alcohol, 
and then two or three drops added of an iodine solution, which is 
prepared as follows: 0.63 gramme of iodine and 0.75 gramme of 
corrosive sublimate are each dissolved separately in 125 c.c. of 
alcohol, poured together, and then 250 c.c. of pure hydrochloric 
acid added. In the presence of even faint traces of bile, a distinct 
green color is obtained. The reaction can be hastened by placing 
the test-tube in hot water for a few minutes. Indican and hemo- 
globin do not interfere with the reaction. The presence of one- 
tenth milligram of bilirubin in 100 c.c. of urine still gives a posi- 
tive result. Where the above tests are negative, a few drops of 
blood may be drawn and centrifuged in a capillary tube. In the 
presence of bile, the clear supernatant fluid will be tinged yellow, 
often before the bile appears in the urine. 

Bile Acids. — Bile acids are always present when bile pigments 
are found, so that separate tests are unnecessary. The test gen- 
erally employed is that of Pettenkofer. Solutions of bile acid or 
their salts exhibit a brilliant cherry red color, changing on stand- 
ing to a deep purple, when treated with concentrated sulphuric 
acid after the addition of a few drops of a 25 per cent, solution of 
cane sugar. The temperature of the mixture should be kept as 
low as possible, and an excess of sugar should be avoided on account 
of the danger of producing caramel. 

Pathological Urobilin. — Ten to 20 c.c. of urine, which is usually 
1 Deutsch. Arch. f. klin. Med., vol. 78. Nos. 1 and 2. 



104 EXAMINATION OF URINE. 

orange-colored with yellowish foam, are extracted with chloro- 
form by shaking and the extract then treated with a few drops 
of dilute Gram's solution. On further adding dilute sodium 
hydrate, the chloroform extract will turn yellow and exhibit a beau- 
tiful green fluorescence. 

In the presence of mere traces, the urine must be extracted 
with amyl alcohol, and the alcoholic extract then treated with a 
concentrated solution of zinc chloride in spirits of ammonia. In 
the presence of urobilin there will be a greenish fluoresence and 
an absorption band between C and F. 

Occasionally urobilin may be found in the blood before it has 
appeared in the urine. About 1.5 c.c. of blood are drawn from 
the finger and mixed with the same amount of 1-1,000 calc, 
oxalate solution. The tube is then placed in the centrifuge 
and the clear fluid rjourecl off. An equal amount of 10 per cent, 
zinc acetate solution is added and the mixture again placed in the 
centrifuge. The supernatant fluid is then examined for the 
fluorescence and spectrum bands. 

The use of zinc acetate has also been recommended for the urine 
by Schlesinger, 1 since it is much more delicate than the chloride 
and does not require the addition of ammonia. Furthermore, 
bilirubin and other pigments are precipitated, and do not interfere. 
The urine is simply mixed with an equal amount of 10 per cent, 
solution of zinc acetate in absolute alcohol and filtered, when the 
filtrate will exhibit the fluorescence, especially when the rays of 
light are concentrated upon it with a convex lens. 

Fat. — Fat in urine is easily identified under the microscope 
as highly refractive globules, which stain black with osmic acid. 
If a quantitative analysis is desired, the urine may be extracted 
with ether and the ether then evaporated. 

Leucin and Tyrosin. — -In order to examine for leucin and tyrosin, 
the urine must be concentrated on the water-bath to about one- 
tenth its original volume, and then treated with an equal amount 
of alcohol. After standing a short time, the sediment should be 
examined for the characteristic crystals. Sometimes it is neces- 
sary to first precipitate the urine with lead acetate, filter, and 
remove the excess of lead with sulphuretted hydrogen. The 
crystals, when present, can be further identified as follows: The 
sediment is filtered off, washed with water, dissolved in ammonia, 
to which a little ammonium carbonate has been added. The solu- 
tion is allowed to evaporate, when the tyrosin remains behind. 
1 Deutseh. med. Woeh., Aug. 6. 1903. 



TESTS FOR ABNORMAL CONSTITUENTS. 1Q5 

A few crystals arc moistened with a few drops of concentrated 
sulphuric acid, covered, and set aside for half an hour. They are 
then diluted with water, heated and while hot, saturated with cal- 
cium carbonate, and the solution filtered. The filtrate will assume 
a violet color when heated with a few drops of very dilute chloride 
of iron.' Tor identifying leucin, the sediment is treated with a 
small amount of alcohol, in which leucin is more soluble than 
tyrosin. The alcohol is then allowed to evaporate and a portion -of 
the residue treated upon platinum foil with nitric acid, when a 
colorless residue is obtained, which forms an oily droplet when 
heated with a few drops of sodium hydrate solution. 

Cystin. — Cystin can be recognized by its characteristic crystals. 
If the sediment does not contain these crystals, the urine should 
be strongly acidified with "acetic acid and examined a second time. 
Frequently an odor of hydrogen sulphide is noticed after the urine 
has stood for some time. 

Alkapton.— The presence of alkapton will cause reduction of 
Tehling's solution, but not of Xylander's. Ammoniacal silver 
solution is reduced in the cold and ferric chloride gives a tem- 
porary, bluish-green color. If treated with Millon's reagent, a yel- 
low precipitate will slowly form, gradually turning to orange. 
On heating, the color of the precipitate readily changes to light 
terra-cotta red. Upon exposure to air, the urine will turn reddish- 
brown, Phenylhydrazine, fermentation, polariscopy and the pen- 
tose reagent will give negative results. Urines containing phenol 
or melanin may also turn dark on standing, but these bodies can 
be. recognized by their special tests. 

Diazo Reaction. — Tor the diazo reaction, Ehrlich employs two 
solutions : one containing 5 per cent, hydrochloric acid and 1 per 
cent, sulphanilic acid, and another containing 0.5 per cent, sodium 
nitrite. The two solutions are mixed in the proportion of 40 :1 
immediately before using. It is most convenient to use a long, 
narrow cylindrical graduate which is filled up to 2.5 c.c. with the 
sulphanilic acid solution. One drop of sodium nitrite solution is 
then added with a dropper, and then urine up to the 5 c.c. mark. 
By means of a pipette, a few c.c. of ammonia water are then floated 
upon the mixture. With every urine, a colored ring will form 
at the line of contact, but while the hue is orange or reddish-brown 
under ordinary circumstances, it is distinctly crimson or garnet- 
colored if the reaction is positive. If the graduate be now shaken 
(this should never be done with the thumb, but with a stopper, 
since typhoid urine frequently contains typhoid bacilli), the foam 



106 EXAMINATION OF URINE. 

will also be a decided red. Furthermore, the mixture may be 
poured into a porcelain basin containing much water, when a beau- 
tiful salmon color will be obtained. Ehrlich states that on stand- 
ing a green precipitate will form in the alkalinized mixture, but 
this is only the case if the reaction is strongly positive. 

Dimethylamidobenzaldehyde Reaction.- — A few cubic centimeters 
of urine in a test-tube are treated with five to ten drops of a 2 
per cent, solution of dimethylamidobenzaldehyde in equal parts 
of water and concentrated hydrochloric acid; the mixture is set 
aside or agitated for a few minutes and the color then noted. The 
reaction is positive, if a distinct cherry-red develops. 

Skatoxyl. — A few c.c. of urine are treated with hydrochloric 
acid and diluted chloride of lime solution, just like for the indol 
reaction, but instead of chloroform, amyl alcohol is added. On 
shaking the test-tube (this must be done very carefully as the amyl 
alcohol emulsifies easily) a brown color will be imparted to the 
amyl alcohol, due to skatoxyl. Some of the color will also, as a 
rule, be taken up by chloroform and will color this pink. 

Phenol. — Millon's reagent (mercury, one part; fuming nitric 
acid, one part; water, two parts) will give a brick-red precipitate 
on boiling. Furthermore, ten c.c. of urine may be boiled in a test- 
tube with a few c.c. of nitric acid. On cooling, some bromine 
water is then added. A pronounced turbidity or a precipitate 
indicates the presence of phenol. A few drops of sodium hypo- 
chlorite gives a blue color, and if heated with iodine and sodium 
hydrate solution a red, amorphous precipitate forms. Whenever 
an appreciable quantity of phenol is present, chloride of iron will 
give a violet or greenish color. If it is desired to test for other 
substances which give the same reaction, the phenol must first be 
removed by shaking out with ether after the fluid has been rendered 
strongly alkaline with sodium carbonate. 

Rosenbach's Reaction. — A number of years ago, Rosenbach de- 
scribed the following reaction: If nitric acid is added drop by 
drop to boiling urine, the urine will turn burgundy-red with bluish- 
red foam. With more nitric acid, the color will change to yel- 
lowish-red and yellow. By adding ammonia, a bluish-red precipi- 
tate will form which will dissolve in an excess with brown color. 
The reaction seems to be due to the oxidation of indican and skatol 
and possesses the same significance as the test for these. 

Lactic Acid. — The urine is evaporated on a water-bath to a 
thick syrup and extracted with 95 per cent, alcohol. This is 
decanted after twenty-four hours, evaporated to a syrup, acidified 



TEXTS FOR ABNORMAL CONSTITUENTS. 107 

with dilute sulphuric acid and extracted with ether till this no 
longer reacts acid. The ether is then distilled off and the residue 
dissolved in water and tested as usual for lactic acid. 

Volatile Fatty Acids. — For the quantitative estimation of acetic, 
formic, etc.. acids, a certain amount of fresh urine is distilled 
with sulphuric acid and the distillate then titrated with deci- 
normal sodium hydrate solution. The only other acid which might 
distil over is benzoic acid, but this is of little consequence. The 
result is expressed in the same number of c.c. of decinormal sul- 
phuric acid. The identification of the various acids requires an 
elaborate chemical analysis. 

Gases. — If hydrogen sulphide is suspected, a strip of filter-paper 
moistened in sodium hydrate and lead acetate solution is held over 
the urine. After a varying length of time this will be colored black 
if the gas is present. 

Ptomaines. — The poisonous diamines which may occur in the 
urine are isolated as follows: The urine of twenty-four hours is 
shaken with a 10 per cent, solution of sodium hydrate and benzoyl 
chloride until the odor of the latter has disappeared. The precipi- 
tate is filtered off and digested with alcohol The filtered alcoholic 
extract is concentrated to a small volume and poured into about 
-30 times the amount of water. After twelve to forty-eight hours, 
the benzoylated diamines separate out in white crystals. 

Drugs. — Lead. — A strip of bright magnesium wire is placed in 
the urine. Ammonium oxalate is then added to the fluid in the 
proportion of 1 :150. In one hour or sooner, a gray coating will 
be noticed on the magnesium, which can be further identified as 
lead by washing and drying and finally heating with a crystal of 
iodine. A yellow stain will show the presence of lead or cadmium. 
The latter can be disregarded. 

Mercury. — Five c.c. of egg albumin are rubbed up in a mortar 
with the same amount of saturated salt solution and dissolved in 
500 c.c. of urine. The fluid is then heated upon a water-bath until 
all the albumin has coagulated. The precipitated albumin is col- 
lected upon a filter, dried and rubbed up in a mortar with 10 c.c. 
of muriatic acid. Then 40 c.c. more of acid are added and the 
mixture set aside in a beaker in which, a copper spiral has been 
suspended. After twenty-four hours the spiral is washed with cold 
and hot water, alcohol and ether, and dried in tne air. It is then 
introduced into a dry glass tube closed at one end. At the upper 
end of the spiral a small crystal of iodine is sublimed by heating, 
finallv the entire glass tube is ofentlv heated. The mercurv will 



108 EXAMINATION OF URINE. 

also sublime and form a brick-red ring of iodide of mercury on 
the inside of the tube. The width of the ring will be proportioned 
to the amount of mercury present. The test is very delicate, for 
it will be positive in the presence of 0.0005 gramme mercury. 

Arsenic. — One c.c. of urine is mixed with 1 c.c. dilute sulphuric 
or muriatic acid and a piece of chemically pure zinc. The test- 
tube is closed with a cotton plug and covered with a piece of filter- 
paper moistened with concentrated silver nitrate solution. In the 
presence of arsenic, a lemon-yellow color will develop which will 
soon turn black. 

Iodides. — Ten to 15 c.c. of urine are shaken with 5-10 drops 
of concentrated, yellow nitric acid and 1-2 c.c. chloroform. In the 
presence of iodine, the chloroform will turn violet and the addition 
of thiosulphate of soda will again cause the color to disappear. 
With the usual indican tests, a violet color is also generally 
obtained. 

Bromides. — Bromides can be detected with the above tests since 
free bromine will tinge the chloroform brown. Or the urine may 
be heated with a small amount of sulphuric and chromic acids. In 
the presence of bromine, a piece of filter-paper saturated with 
fluorescin solution and held over the flask, will turn red. If iodine 
is also present in the urine, this latter must be treated with sul- 
phuric acid saturated with the fumes of nitric acid. By shaking 
with carbon disulphide, the iodine can then be removed. 

Chlorate of Potash. — Ten to 15 c.c. of urine are warmed with 
one-fourth its volume concentrated hydrochloric acid, when a play 
of colors from red, bluish-violet, yellow to colorless will be observed. 
If much chlorate is present, free chlorine may escape. 

Chrysophanic Acid appears in the urine after the use of rhubarb, 
senna, chrvsorobin and cascara saarada. The color of the urine 
is generally yellowish, turning to red upon the addition of alkali 
and again disappearing when acidified Avith acetic acid. With 
the indican test, the chloroform will be tinged green and 
[Nylander's solution will be reduced. 

Santonin. — Santonin gives the same reactions as chrysophanic 
acid, but is insoluble in ether. If the urine is shaken out with 
ether, a few drops of sodium hydrate added to the extract will not 
change the color. 

Salicylic Acid. — A few drops of chloride of iron will color the 
urine dark red to bluish-violet. Antipyrine and phenacetine may 
give similar reactions. Muriatic acid should then be added to the 
urine tested as above until a red color is still visible. On now 



TESTS FOR ABNORMAL CONSTITUENTS. 109 

shaking with acetic ether, the red' color will disappear entirely if 
due to salicylic acid. 

Antipyrine. — Chloride of iron will give a dark Ted color which, 
does not disappear on boiling (differentiation from diacetic acid) 
or shaking with acetic ether (differentiation from salicylic acid). 
A ruby-red crystalline sediment will appear if the urine is treated 
with a drop of muriatic acid and Lugol's solution. 

Phenacet'uie. — Chloride of iron will give a brownish-red color; 
two drops of muriatic, two drops of a 1 per cent, sodium nitrite 
solution, some soda lye and alkaline aqueous a-naphthol solution 
will give a red color, which turns violet if more muriatic acid is 
added. 

Copaiba. — Muriatic acid will give a pink color, which will 
become violet on boiling. See also under albumin tests. 

Urotropine. — Urine containing urotropine will turn yellow if 
treated with bromine water. The precipitate is soluble in an excess 
of urine. 

Chloroform. — Fehling's solution will be positive. If the urine 
is distilled on a water-bath in a stream of carbonic acid, the dis- 
tillate will give off a disagreeable odor of phenylisocyanate if 
heated with aniline oil and alcoholic potash lye. 

Sulphonal and Trional. — In order to detect hematoporphyrin, 
20-25 c.c. of urine are precipitated with a solution consisting of 
equal parts of saturated barium hydrate and 10 per cent, barium 
chloride. The precipitate is collected on a filter, washed with 
water and alcohol, then mixed with a few drops of muriatic acid 
and a small amount of alcohol. After a few minutes the mixture 
is warmed on a water-bath and filtered. The reddish filtrate, if 
spectroscoped, will give two absorption bands, one before I), and 
the other between D and E. 

Morphine. — The urine will give Trommer's test and turn polar- 
ized light to the left (morphine glycuronic acid). But it may also 
be dextrorotatory owing to the presence of glucose, or give the 
orcin reaction for pentoses. 

Tannic Acid gives a black color with tincture chloride of iron. 

Turpentine. — The urine smells of violets and turns polarized 
light to the left (turpentine glycuronic acid). 

Orthoform. — Chromic acid will give a dark red color. 

Pyramidon. — The urine has a distinct pink color, which can be 
dissolved out by means of ether, chloroform or amylic alcohol. 

Naphthaline gives a blue fluorescence with a few drops of am- 
monia. Another test is to add to 6 c.c. of urine, 4 drops of chloride 



110 EXAMINATION OF URINE. 

of lime solution and a few drops of hydrochloric acid. The urine 
becomes yellow, and if shaken out with ether the color can be 
extracted. If this ether is layered over a 1 per cent, resorcin 
solution and rendered alkaline with a few drops of ammonia, the 
resorcine is colored a blue-green ; with nitric acid, the color will 
be cherry red. 

Resorcin gives the above test directly. 



CHAPTER VII. 

RENAL AND BLADDER STONES. 

According to their chief constituents, renal and bladder stones 
are subdivided into those consisting of 

1. Urates (chiefly free uric acid, acid urate of sodium and less 
frequently, urate of ammonia). 

2. Phosphates (chiefly the phosphates of calcium and magne- 
sium and carbonate of calcium). 

3. Oxalates (calcium oxalate). 

4. Cystin and xanthin. 

5. Mixed stones. 

GENERAL PROPERTIES. 

Coloe. — Uratic stones are yellow to dark brown; phosphatic 
stones, grey or greyish-yellow. Those consisting of oxalate of lime 
are reddish-brown or black, but the smaller ones frequently appear 
white or grey. Stones consisting of cystin are colored pale yellow ; 
those of xanthin, light brown. 

Sueface. — A warty (mulberry) surface is characteristic for 
oxalic stones ; uratic stones are less rough and the others of the list 
generally smooth. 

Consistency. — Cystin stones are frequently as soft as wax; 
phosphatic stones, brittle and chalky, oxalic stones are the hardest 
of all, then come the uratic stones. 

CHEMICAL EXAMINATION. 

The calculus is divided into two halves by means of a scroll saw. 
The surface is then washed off in water, so that the nucleus and 
layers come clearly to view. A portion of the nucleus and each 
layer is then scraped off and examined separately. If the stone 
is not layered, but is uniform in structure, it is simply pulverized 
in a mortar. A small sample of the powder is heated on a platinum 
foil. 

1. The powder burns up almost entirely and the amount of ash 
remaining behind is slight. Such stones consist of uric acid, 
urates, xanthin or cystin. Urates and xanthin will burn without 
flame and will give off an odor of prussic acid ; cystin burns with a 

(111) 



112 EXAMINATION OF URINE. 

bluish flame and odor of sulphurous acid.. For more accurate 
analysis, a second sample of the powder is evaporated to dryness 
in a porcelain dish with a few drops of nitric acid. If the residue 
gives a purple color with ammonia and violet color with lye 
(murexid test), the powder contains uric acid or urates. If the 
powder leaves no residue on heating to red heat, it is pure uric 
acid ; if ammonia is evolved on treating some of the original powder 
with soda lye we are dealing with the ammonium salt/ The other 
urates will leave a slight residue on heating to red heat Xanthin 
is present if the murexid test with ammonia is negative, but if 
soda lye will give a beautiful red color. Cystin reacts neither with 
ammonia nor with soda lye, but is readily soluble in ammonia. 
On slowly evaporating the latter, characteristic hexagonal plates 
will form. 

2. The powder does not burn up, but blackens and leaves con- 
siderable residue. It may then consist of phosphates, carbonates 
or oxalates. A small portion of the powder is carefully warmed 
with dilute muriatic acid, which will dissolve the greater portion. 
We now cool, filter, dilute with water and add ammonia until 
strongly alkaline. A precipitate may consist of 

(a) Phosphate of lime or magnesia. 

(b) Triple phosphate. 

(c) Oxalate of lime. 

The precipitate is now separated from the fluid by centrifuging 
and then shaken with acetic acid. Earthy phosphates and triple 
phosphate will dissolve, while oxalate of lime will remain behind 
and can be identified under the microscope. The filtered solution 
is then tested as follows : 1. On adding ammonium molybdate 
and nitric acid and warming up to 60° O, a yellow precipitate will 
indicate the presence of phosphoric acid. 2. The other half of the 
filtrate is then treated with soda lye; the resulting precipitate is 
examined microscopically for amorphous or crystalline earthy 
phosphates or for crystalline triple phosphate. 

If no precipitate has been obtained on adding ammonia to the 
solution of the powder in hydrochloric acid, the stone must consist 
of calcium or magnesium carbonate. If muriatic acid be dropped 
on the stone, carbonic acid gas will then be evolved. Oxalate of 
ammonia is added to half of the ammoniacal solution ; a precipitate 
of oxalate of lime will indicate the presence of calcium. The other 
half is treated with sodium phosphate, when a precipitate of triple 
phosphate will occur in the presence of magnesia. 

The portion of the stone insoluble in muriatic acid should be 
tested for uric acid (murexid test). 



CHAPTER VIII. 

MICROSCOPICAL EXAMINATION OF URINE. 

Every physical and chemical examination of urine should be 
supplemented by a thorough microscopical examination, for which 
purpose a good compound instrument with low and high-power 
lenses is absolutely essential. 

When time is not pressing, the urine may be allowed to sediment 
in a conical glass for a few hours ; the deposit is then sucked up 
by means of a long pipette and a drop of it examined on a slide 
Avith a cover-slip, first with a low, then with the high power. It 
is always, however, better to centrifuge the urine with an instru- 
ment run by .hand or water-power or by electricity. The latter 
generally have the highest speed and one to three minutes will 
suffice to completely throw down the suspended matter. For accu- 
rate work it is best to combine sedimentation with centrifuging. 
The urine is poured into a conical glass, after a sufficient amount 
lias been removed for the chemical tests, and is allowed to settle for 
several hours ; the sediment is then sucked up and centrifuged. 
For still more accurate work, the entire quantity of tw r enty-four 
hours is allowed to settle after a piece of camphor or a crystal of 
thymol has been added to prevent decomposition (chloroform is 
often recommended, but is undesirable since it settles to the bottom 
and mixed with the deposit; formaline is also undesirable, since 
it interferes with some of the chemical tests). In such cases the 
sediment may be more abundant and it will be necessary to 
examine more than one slide. 

Frequently difficulty will be experienced in completely clearing 
the urine by means of the centrifuge. This may be due to the 
presence of mucus, bacteria or urates. Thick, mucinous urine can 
be easily rendered thin by digesting the urine for several hours in 
a warm place with a pinch of pancreatin and bicarbonate of soda. 
A turbidity caused by uric acid or urates will readily dissolve on 
warming, but will reprecipitate unless the sediment is examined at 
once on a warm slide. Frequently, too, the sediment will be so 
abundant that finer elements, such as casts, are entirely obscured. 
If the urine has been alkaline and the deposit consists chiefly of 
phosphates, the addition of a few drops of acetic acid will cause 
8 (113) 



114 EXAMINATION OF URINE. 

these to disappear. In the case of urates, simple warming will 
generally suffice, while with excessive pus the sediment must be 
diluted. 

The following is a list of elements which may occur in urine 
(the more common ones are in italics) : 

A. CRYSTALLINE OR AMORPHOUS ELEMENTS. 

(a) IN ACID UEINE. 

1. Uric acid. 

2. Sodium or potassium urate. 

3. Calcium oxalate. 

4. Primary calcium phosphate (only when very acid). 

5. Secondary calcium phosphate. 1 , , ,. , ,. ., 

6. Tricalcie or trimagnesic phosphate. } on1 ^ when s^tly .acid. 

7. Triple phosphate. 

8. Calcium sulphate. 

9. Leucin and tyrosin. 

10. Hippuric acid. 

11. Xanthin. 

12. Soaps of lime and magnesia. 

13. Bilirubin. 

14. Hematoidin. 

^b) IN ALKALINE URINE. 

1. Secondary calcic phosphate. 

2. Tricalcie or magnesic phosphate. 

3. Triple phosphate. 

4. Calcic carbonate. 

5. Ammonium urate. 

6. Indigo 

7. Cyst in. 

B. FORMED ELEMENTS. 

1. Epithelial cells. 

2. Pus cells. 

3. Red blood cells. 

4. Casts. 

5. Parasites and bacteria. 

6. Tumor particles. 

7. Spermatozoa. 

8. Fat. 

9. Vegetable matter, hairs, cotton fibres, grass, pollen, etc. 

Uric Acid. — This often crystallizes in whetstone form, the crystals 
occurring either singly or in the form of rosettes, composed of long, 
narrow slabs with rounded ends. Dumbbell-shaped crystals, larger 
than those of calcium oxalate, are also seen occasionally. The 
crystals are the largest which are found ordinarily in the urine; 
they form the so-called brick-dust or later itious deposit so often 
seen in cold weather, and their characteristic red color is due to 
uroerythrin. They dissolve readily on heating and by the addition 
of alkalies, and the murexid test is characteristic. 

A deposit of uric acid does not necessarily mean an excess of 



MICROSCOPICAL EXAMINATION OF URINE. 



115 



this substance in the urine, nor are the crystals always thrown 
down if an excess is present. 

Sodium and Potassium Urate are always amorphous and colored. 
The fine granules may be so abundant that they obscure the 
entire field and coat formed elements (structures resembling 
coarsely granular casts) may sometimes be seen. They dissolve on 
warming, and the addition of acids will precipitate uric acid in 
form of whetstone crystals or rhombic plates. 

Calcium Oxalate. — Crystals of calcium oxalate belong to the most 
characteristic elements found in urine. They form diamond- 
shaped octahedra, which, are colorless, highly refractive and rarely 
attain a large size. One or two opposite axes may be elongated. 
Dumb-bell forms may be seen made up of two bundles of needle- 
like crystals united in the form of the figure 8. They are usually 
associated with or adherent to casts and differ from similar uric 
acid crystals, in that they are radially striated, shorter and thicker 
and lack the characteristic color. According to Simon there is 
also an amorphous variety. Alkalies and 'acids do not affect the 
crystals. The diagnosis of oxaluria should never be made from 
the presence of the crystals, even when they are abundant. 

Fig. 28. 




Calcium phosphate crystals. (Musser.) 



Primary Calcium Phosphate ( Monocalcium Phosphate j occurs 
rarely together with uric acid in strongly acid urines. The crystals 
resemble uric acid, but are colorless and readily soluble in acetic 
acid. 



116 



EXAMINATION. OF URINE. 



Secondary Calcium Phosphate and tricalcic and magnesic phos- 
phate are very rare in acid urines, but common in alkaline. They 
generally do not form characteristic crystals by transparent 
granules, like the urates, but colorless. They do not disappear on 



Fig. 29. 




Crystalline phosphates. (Finlayson.) 

heating, but are readily dissolved on adding acetic acid. Rarely 
acicular, star-shaped crystals are observed; or, in the case of 
magnesia, highly refractive plates. 

Triple Phosphate ( Ammonia-Magnesium Phosphate ) is also very 
rare in feeblv acid urine, but common in alkaline. The crvstals 



Fig. 30. 




Moiioealcium phosphate crystals. 

are usually large rhombic prisms of coffin-lid shape, but smaller 
ones may be mistaken for calcium oxalate. Their solubility ii) 
acetic acid will, however, prevent this error. In alkaline urines, 
there may be in addition a variety of star-shaped, "snow-flake' 7 
crvstals, with four, five or more arms and feathery borders. 



MICROSCOPICAL EXAMINATION OF VHIXE. 



11' 



Calcium Phosphate li as only been- observed in a few cases. The 
reaction here is strongly acid. The crystals appear as long, color- 



Fig. 31. 




Various forms of triple phosphates. (Finlayson.) 

Fig. 32. 




Fig. 33. 




Crystals of leucin (different forms). (Crystals of kreatinin-zinc chloride resemble the 
leucin crystals depicted at a.) The crystals figured to the right consist of comparatively 
impure leucin. (Charles.) 

less needles or elongated prismatic tablets which do not dissolve in 
acids or ammonia. 



118 



EXAMINATION OF URINE. 



Leucin and Tyrosin. — Leucin occurs in form of spherules of 
variable size which closely resemble fat, but can be easily dis- 



Fig. 34. 




Tyrosin crystals. (Charles. 



Fig. 35. 




^>.o 



a, Crystals of xanthin (Salkowski) : 6. Crystals of cystin. (Robin). 

Fig. 36. 




yggr / 

Lime and magnesium soaps, (v. Jaksch.) 



tiuguished by their insolubility in ether, their brown color and the 
presence of concentric striations and fine radiating lines. Kreatinin 
zinc chloride closely resembles certain types. 



MICROSCOPICAL EXAMINATION OF URINE. 



119 



Ty rosin appears as very fine needles, usually grouped in bundles, 
crossing each other at various angles. They are insoluble in acetic 
acid, but soluble in ammonia and hydrochloric acid. 

Xanthin crystals closely resemble some of the colorless crystals of 
uric acid. 

Soaps of Lime and Magnesia. — Calcium and magnesium salts of 




Calcium carbonate crystals. 

certain higher fatty acids are of very rare occurrence. They 
closely resemble tyrosin in appearance, but do not give the reac- 
tions of this substance. 

Bilirubin forms yellow or red rhombic plates in icteric urine. 
They dissolve in alkalies and chloroform, but not in ether and give 
the usual bile reactions. 




Ammonium urate crystals. 



Hematoidin is also very rare and can hardly be distinguished 
from bilirubin. It has been encountered in various diseases of the 
kidney and bladder, attended with bleeding. 

Calcium Carbonate appears under the microscope in the form 
of minute granules, occurring singly or arranged in masses. Dumb: 



120 



EXAMINATION OF URINE. 



bell forms also occur. They are easily identified by the evolution 
of gas on addition of an acid. 

Ammonium Urate is characteristic of ammoniacal fermentation. 



Fig. 39. 




Crystals of cystin spontaneously voided with urine. (Roberts.) 

The crystals cannot be mistaken for anything else; they are gen- 
erally spherical, amorphous, brown in color and beset with 

Fig. 40. 




Crystals of eholesterin. (Musser. 



spicules, but may also appear as delicate needles arranged into a 
spherical body. They are dissolved by acid with the subsequent 
separation of characteristic crystals of uric acid. 



MICROSCOPICAL EXAMINATION OF URINE. 



121 



Indigo occurs as delicate blue needles, or as amorphous granules 
in urines that have undergone decomposition. Their presence is 
probably the result of bacterial decomposition of indican. Rarely 
calculi consist almost entirely of indigo-blue. 

Cystin occurs in the form of colorless, hexagonal plates, which 
are soluble in ammonia and hydrochloric acid and insoluble in 
acetic acid, water, alcohol and ether. When heated, they burn with a 
bluish-creeii flame without melting. 

Cholesterin is rarely found in the form of large, flat, colorless 
plates, with ragged edges. Frequently one corner appears punched 
out. 

B. Formed Elements. 

Epithelial Cells. — It may not be amiss to review briefly the 
characteristics of the epithelial lining of the genito-urinary tract. 

Fig. 41.' 




Epithelial cells from the pelvis of a human kidney. (Rieder.) 

In the convoluted tubules, the cells are but little larger than leuco- 
cytes with polyhedral cell body, but in the descending loop of 
Henle they become natter and more squamous in type. The 
ascending limb presents similar but somewhat higher cells, while in 
the distal convoluted portion and the collecting tubules, the cells 
gradually assume a cylindrical shape and increase in height with 
the width of the tubule. 

In the renal pelvis and ureters, the cells are of a transitional 



122 



EXAMINATION OF URINE. 



type, that is, cells which rapidly change from the columnar of the 
deeper layer to the stratified scaly of the superficial. In the pelvis 
the superficial cells frequently have a distinct process which makes 
them appear conical or caudate. 

The epithelium of the bladder so closely resembles that of the 
ureter and pelvis that it is often impossible to distinguish between 
the two. At the neck of the bladder, the cells may also be caudate, 
but the processes generally have a greater length. 

In the female urethra the lining is generally stratified squamous, 
but may be simple columnar. In the prostatic portion of the male 
urethra, the epithelium resembles that of the bladder; in the mem- 



Fig. 42. 




Epithelial cells from the human ureter. (Rieder.) 

branous division it gradually passes into the stratified columnar 
variety, which in the . spongy part is transformed to a simple 
columnar epithelium. In the fossa navicularis and the glans, the 
stratified squamous type is again encountered. 

The vagina is lined by large flat elements which are very char- 
acteristic. 

From this it may be seen that while there may be consider- 
able difference in appearance between renal and vaginal cells, the 
lining cells of the intermediary tract do not differ so widely that 
their probable origin can be determined by their size and shape. 
Added to this is the fact that the urine always changes the shape of 
the cells to some degree, and finer structures, such as the striations 



MICROSCOPICAL EXAM1XATWX OF URINE. 



123 



of the renai cells, are never preserved. Some claim that the identi- 
fication of the epithelial cells of the different portions of the genito- 



Fig. 43. 




Fig. 44. 




Epithelial cells from the mucous membrane of the human bladder. (Rieder.) 
Fig. 43. — From the urinary sediment from a case of cystitis. The cells are somewhat 
swollen after maceration in the altered urine. 

Fig. 41 — Removed from the internal surface of a normal bladder. 



urinary tract is an easy task, and even go so far as to locate the 
portion of the kidney affected in renal disease, but the careful 



124 



EXAMINATION OF URINE. 



examination of many thousands of sediments and comparison with 
clinical history and symptomatology has convinced us that such 
differentiation is based chiefly on imagination. 



Fig. 4: 




Epithelium from Hie human male urethia. (Kieder.) 

For practical purposes, we may divide the epithelial cells com- 
monly encountered in sediments, into three types : 1. Round. 2. 
Caudate. 3. Flat cells. Round cells are usually derived from the 



Fig. 40 




End of epithelial 
/ ' cell 

m Epithelial 
A-vcll villi 
A tiro nuclei 

uLencocyte 






From a section through the mucous membrane of an ape's urinary Madder. X 3C0. 



uriniferous tubules or the deeper layers of the mucosa of the pelvis 
or lower genito-urinary tract. They are round or cubical, slightly 
larger than a leucocyte, but with distinct, vesicular nucleus and 



MICROSCOPICAL EXAMINATION" OF U1UXE. 123 

very sharp contours. Frequently the protoplasm -hows fatty 
degeneration. A diagnosis of "renal epithelium" is only admis- 
sible, if albumin and casts, are also present (especially if the cells 
adhere to the casts), or if the cells occur in typical strings, like in 
the uriniferous tubule-. If found with considerable pus but with- 
out casts or more than traces of albumin, a pyelitis is possible, 
especially if the cell- are joined in a shingle-like manner, But^ 
it must never be forgotten that similar elements occur in the deeper 
layers of almost the entire genito-urinary tract from the pelvis 
down, and that a diagnosis in the absence of other characteristic 
elements is extremely hazardous. 

An important observation on renal cells, is that of Quincke. 1 In. 
a case of unilateral hydronephrosis, the sediment was rich in cells, 
24-30 mikra in diameter, with their entire cell body filled with' 
very coarse granules, disappearing after the addition of acetic acid. 
These elements were probably epithelial cells derived from the 
straight tubules, altered by pressure; since they were subsequently 
found in similar cases, they are of diagnostic value and indicate 
that a slow atrophy is in progress. 

Renal cells may occur in all diseases of the kidney, but are 
especially marked in the desquamative types. If they contain 
droplets of fat, it may be possible to determine the existence of a 
degenerative process. 

2. Caudate Cells. — ('ells with a distinct conical process are 
generally derived from the pelvis of the kidney or the neck of the 
bladder. The statement that caudate cells are pathognomonic of 
pyelitis is passed from one text-book to the other, yet there are few 
of us who would risk a diagnosis on the so-called caudate cells that 
are seen in the urine of pyelitis. There is as yet no simple micro- 
scopic method of differentiating between cystitis and pyelitis. 

3. Flat Epithelium belongs to the normal ingredients of urin- 
ary sediment, especially in women where the desquamation of 
vaginal elements is often so active as to obscure everything else. 
The cells are usually large, polygonal and provided with a w T ell- 
defined nucleus, and the extra-nuclear protoplasm is usually trans- 
parent. In order to distinguish vaginal cells from those of the 
bladder, etc., the urine should be drawn off with a catheter, more- 
over the vaginal cells often occur in sheets. A large number of 
flat epithelial cells is the male (or in the catheterized specimen of 
the female) if not accompanied by much pus, will speak for a catar- 
rhal process of the ureters, bladder or urethra. In the latter two 
instances the increase is much more marked than in the former. 

1 Deutseh. Arch. f. klin. Med., vol. 79, Xos. 3 and 4. 



126 EXAMINATION OF URINE. 

The so-called mucous corpuscles of normal urine are nothing but 
young vesical epithelial cells. 

Leucocytes. — A few pus cells may be encountered in any normal 
urine and their quantity is often increased in men due to 
an old gonorrhea, or in women as a consequence of a vaginal dis- 
charge. Larger amounts indicate disease of the genito-urinary 
tract, but the appearance of the cells alone will not disclose their 
origin. If derived from the kidney, pus and other casts, and small 
epithelial cells may be present ; and the amount of pus is usually 
small except in abscess, if from the pelvis, the urine is acid and 
may also contain caudate cells, while in cystitis, the reaction is 
often alkaline (except in typhoid and colon cystitis) and phos- 
phates are frequently present. 

For the diagnosis of urethral pus, Thompson's two-glass test is 
often employed, that is, the patient is instructed to pass the first 
part of his urine into one glass and the second in another. In 
gonorrhea or other catarrhal conditions of the urethra, only the 
first glass will be cloudy and contain pus cells. 

The largest amounts are seen in pyonephrosis and after the 
rupture of a neighboring abscess into some part of the genito- 
urinary tract, where almost pure pus may be excreted. In acid and 
feebly alkaline urine, the cells are usually well preserved, but in 
very alkaline urine or when the pus comes from an old abscess, it 
is often impossible to identify the individual corpuscles, Avhich 
may even be converted into a gelatinous mass. In such cases the 
following reaction for pus may be employed : The urine is acidi- 
fied with acetic acid, filtered, and the contents of the filter treated 
with a few drops of tincture of guajacum, when in the presence 
of pus the filter-paper will be colored blue. 

Occasionally it is important to enumerate the number of pus- 
cells contained in the urine. For this purpose, the ordinary 
Thoma-Zeiss blood counter is employed, very dilute acetic acid 
being added to the urine if necessary. In general, 5,000 cells to 
the cubic millimeter signify a mild cvstitis, and in severe cases 
50,000 and more may be counted. With many pus cells a trace of 
albumin will occur in the urine, even in the absence of renal 
disease. This applies to the filtered as well as to the unfiltered 
specimen, since some of the albuminous principles of the cells 
always go into solution. * 

Red Cells may occur normally in the urine of women from 
admixture with menstrual blood ; they may also be present in small 
amounts as a result of catheterization or after the passing of 



MICROSCOPICAL EXAMINATION OF URINE. 127 

sounds. Usually, however, red cells point to a distinct pathological 
process somewhere in the genito-urinary tract. If from the 
kidneys, the amount is usually small and intimately mixed with 
the urine, the individual corpuscles often appear as "shadows" and 
epithelial and blood casts are also present. Common conditions 
associated with renal hematuria are the severer types of infectious 
diseases, hyperemia of the kidneys in circulatory disturbance, 
acute and to a less extent, chronic nephritis, stone of the kidney, 
carcinoma or tuberculosis, and, more rarely, renal abscess and 
aneurism, embolism or thrombosis of the renal vessels. As com- 
pared with hemoglobinuria, hematuria is of much more common 
occurrence. Certain poisons (carbolic acid, cantharides, etc.) may 
also be responsible for the presence of blood in the urine. 

Blood coming from the* ureter or renal pelvis is difficult to 
identify, but often long coagula are passed, and there may be other 
signs which point to pelvic or ureteral' disease. 

In vesical hematuria the admixture is a less intimate one, and 
the cells have preserved their normal appearance and rapidly settle 
unless ammoniacal fermentation has set in. Large, irregular clots 
may also be voided. Hematuria may be found with severe cystitis, 
tuberculosis or tumor of the bladder, foreign bodies, or parasites, 

In case the blood is derived from the urethra, after trauma, the 
first portion of the urine voided will contain blood, but not the 
second. 

Urine containing blood will be bright red or more brown. If 
recent, the individual cells can generally be readily identified by 
their size, their pale yellow color and sharp contours. Often, how- 
ever, they are considerably altered by the urine and may appear 
crenated or entirely devoid of color (blood-shadows). In such 
cases it may be necessary to resort to one of the chemical tests for 
blood. 

A peculiar form of hematuria has been described by Senator 
as "renal hemophilia." It does not seem to be associated with 
distinct pathological lesions, and occurs chiefly in neurasthenia. 

Like with pyuria, both the filtered and unfiltered specimens will 
contain traces of albumin in the presence of blood. 

Casts.— The most important morphological structures occurring 
in urine are casts, and every specimen should be most carefully 
examined for these. There is still considerable doubt as to their 
method of formation, but they probably consist of albumin and 
are formed in the convoluted tubules, where they may frequently be 
discovered in situ on hardening and cutting the kidneys of cases of 
nephritic. 



128 



EXAMINATION OF URINE. 



Their significance is in the main the same as that of renal 
albumin, but they tell us more, since their appearance, to a certain 
extent, will disclose the severity of the renal lesion. Then, too, 
they may be frequently found where albumin, even in traces, is 
absent (especially in the very chronic types of interstitial 
nephritis) so that the microscopical examination may enable a diag- 
nosis of nephritis, where the chemical tests have failed. Con- 
versely, renal albuminuria may exist without the presence of casts 
especially in renal congestion, essential albuminuria, or where a 
cystitis is also present and ammoniacal decomposition has destroyed 
the delicate structures. It is a mistake, however, to believe that 

Fig. 47. 




Hyaline casts from a case of acute nephritis; 1, plain hyaline cast; 2, granular deposit on 
hyaline cast; 3, cellular deposit (blood and epithelium). (Musser. ) 



casts invariably mean a nephritis. Personally, the writers have fre- 
quently encountered typical hyaline casts in the urine of patients 
who presented no renal symptoms and where the subsequent his- 
tory, extending over years, removed all doubts as to the presence of 
a nephritis. In persons of advanced years, a scant number of 
hyaline or even finely granular elements, in the absence of albumin, 
need cause no alarm, as they are often only a manifestation of 
slight thickening of the renal vessels. In the opinion of one of 
our foremost clinicians, they may even be regarded as a blessing, 
as they will enforce certain precautions in diet and general living. 
(Plate IV.) 

Casts must never be confounded with pseudo-casts or cylindroids, 



PLATE IV. 



1. Hyaline Casts with Granular Matter and Epithelial Cells 

deposited upon them. 2. Amyloid (waxy) Cast. 

(Musser.) 

(Oc. 4, Ob. D.) Drawn by J. D. Z. Chase. 



FIO. 2. 



. 



(*>' (•• 



- ' 



i 



my 



fe! ■ 



:.<£$ «g 









^ 



*& 






V 7 



/■#•# 






Blood Casts from Case of Acute Nephritis. (Musser.) 

(Oc. 4, Ob. D.) Drawn by J. D. Z. Chase. 



MICROSCOPICAL EXAMINATION OF URINE. 



129 



which resemble them to a certain extent. The former are fre- 
quently formed of cylindrical accumulations of urates, bacteria, 
epithelial cells or detritus, and lack the delicate, uniform matrix of 
true casts. 

Fig. 48. 




Fatty casts from a case of chronic parenchymatous nephritis. iMusser.) 

True casts may be divided into two great classes, hyaline and 
waxy. The former are again subdivided into hyaline, finely or 
coarsely granular, according to the appearance of their surface, 
and into epithelial, pus and blood casts, according to the cells which 
enter into their formation or adhere to their body. 



130 



EXAMINATION OF URIXE. 



Hyaline casts are colorless, very pale and transparent. In the 
presence of bile, they may be tinged yellow. They are best seen 
with the high power and flat mirror, without condensor and with 
the iris diaphragm partly closed. Their structure is generally 
homogenous, their borders parallel and ends rounded. In thickness 
and length they vary considerable, probably with the portion of 
the uriniferous tubule where they originate, and it is always best 
to specify their size. Sometimes the ends are broken off obliquely 
or are spirally elongated and the body may be notched. Their 
identification is facilitated by the addition of Lugol's solution, 
picric acid or fuchsin solution to the sediment. 

Finely granular casts have a distinctly granular surface, which 

Fig. 50. 




Cylindroids. (Mus 



permits them to be identified more readily than hyaline casts. 
Coarsely granular casts are still more easily visible and frequently 
possess a yellow color. Their granules are probably derived from 
the breaking down of renal epithelium cells and consequently they 
indicate a more serious lesion than the hyaline structures. 

Epithelial, pus or blood casts are made up almost entirely of 
cells, or else the cells merely adhere to their surface. They are 
seen only in severe lesions and are not of common occurrence. All 
transition stages between hyaline, granular and cellular casts may 



occur. 



Waxy casts differ from hyaline casts in that they possess a higher 
degree of refraction, a yellow or yellowish-gray color, are usually 
not attacked by acetic acid, and give the amyloid reaction (mahog- 



PLATE V. 




Concretions of Chronic Prostatitis. (Taylor. ) 



PLATE VI 






Jiff • '•• ^ 



••• 



m ™ >// ■ , ^ ■ m m • u 6 / 











* .V*^-' • 'fitful '•/■,', h 



Amyloid Bodies in the Prostatic Tubules shown 
on Transverse Section. (Taylor.) 



MICROSCOPICAL EXAMINATION OF URINE. 



131 



any color with Lugol's solution, which turns to a dirty violet on 
adding dilute sulphuric acid. They may also have granules and 
cells adherent to their surface, hut not as often as hyaline casts. 
Frequently, not entire casts, but only broken pieces are encoun- 
tered. They do not always signify amyloid disease of the kidneys 
and amyloidosis is not necessarily accompanied by the excretion of 
amyloid casts. 

Cylindroids resemble tube-casts in that they are colorless and 
cylindrical, but are less refractive, longer, striated and often 
twisted so that their differentiation, as a rule, is easy. They 
probably consist of mucus and may be encountered in almost every 

urine. 

Fig. 51. 




Spermatozoa from urine. (Musser.) 



Spermatozoa. — Spermatozoa are best seen with the higher 
powers and are easily recognized by their conical head and long 
tail. If found in male urine after intercourse or nocturnal emis- 
sion, they possess no significance. Their constant presence may be 
noted in certain pathological conditions of the seminal passages, 
with spinal diseases and in true spermatorrhea, due to masturba- 
tion or venereal excess. The presence of spermatozoa in the urine 
of little girls may be of great medico-legal importance. (Plates 
V. and VI.) 

Where spermatozoa are present, other characteristic elements 
may be found, such as large, rounded cells, with distinct nucleus, 
which enclose spermatozoa and delicate, cylindrical bodies of homo- 
genous, hyaline structure which are derived from the spermatic 



132 



EXAMINATION OF URIXE. 



canals and have been termed "testicular casts." In diseases of the 
prostate, numerous small shiny granules, the so-called lecithin- 
granules, are sometimes seen, together with rounded and angular 
bodies of concentric structure (corpora amylacea) and star-shaped 
or elongated crystals of spermin. In pure prostatic secretion, these 
will show very readily if a, 1 per cent, solution of ammonium phos- 
phate is added, but this is not the case with urine. 

Tumor -particles. — In papillomatous or carcinomatous tumors 
of the renal pelvis or bladder, small tumor-particles may be voided 

Fig. 52. 




Secretion of chronic prostatitis, showing granular phosphates, degenerated cylindrical 
epithelial cells, and pus. (Taylor.) 



spontaneously, but such occurrence is certainly very rare. Sus- 
picious sheds should be fixed, hardened, cut and stained the usual 
way for identification. Usually the particles will turn out to be 
mucus or blood-clot. 

Fat is readily identified as small, highly refractive granules, 
readily soluble in ether. It is often present accidentally but may 
be due to parasites lodged in the genito 7 urinary tract (chyluria). 

Other Elements. — Various animal parasites may from time 
to time be encountered in the urine. The most common of these 
are: (1) Trichomonas vaginalis, which is derived from the vagina 
and occasionally gives rise to hematuria. (2) Bilharzia liematobia. 



MICROSCOPICAL EXAMINATION OF URINE. 133 

The eggs are oval, 0.16 mm. long and 0.05 mme. broad, and are 
provided with a distinct spike-like projection which issues from 
one extremity or the side. They can be seen with the low power 
and are most frequently found in the last bloody drops of urine 
voided. (3) Filaria. Filaria embryos may be found in the urine 



Fig. 53. 





in cases of filarial chyluria. They should be looked for in the 
coagulum, a bit of which is teased out and pressed between two 
slides. Cases are common in Egypt, but very rare in the United 
States. (1) Echinococcus booklets and fragments of cysts. The 
former can be easily identified under the microscope, the latter give 



Fig. 54. 




Fig. 55. 




the chitin reaction. (5) Amoebae. (6) Eustrongylus gigas. (7) 
Distoma hematobium. These three are very rare. (8) Occasion- 
ally the eggs of intestinal parasites accidentally contaminate the 
urine. 

Concerning bacteria, see special chapter. 



134 



EXAMINATION OF URINE. 



Starch cells and lycopodium grains are not infrequent in females 
who use dusting powder. The former are oval, concentrically 
striated and turn violet on the addition of iodine solution. The 



Fig. 56. 




£° 



Fig. 57. 



.SU 



&. 



Corn starch. 



Rice starch 



Fig. 58. 




Wheat starch. 



pollen grains of lycopodium appear as sphero-tetrahedonal bodies, 
the surfaces being reticulated and the edges beset with short pro- 
jections. 



Fig. 59. 




Lycopodium. 

Foreign bodies of all description may be seen in the urine in 
hysteria. Care should also be taken to keep the urine in clean 
receptacles, since many admixtures, bacterial and otherwise, may 
be derived from the sediment contained in bottles. Cotton fibres 
are universal. 



CHAPTER IX. 

BACTERIOLOGY OF URINE. 

The urine as it leaves the kidneys and as it is stored in the 
bladder, is practically a sterile fluid in healthy individuals. If 
collected aseptically with a catheter and passed into a sterile recep- 
tacle, it may remain unaltered for a long period, but during the 
normal act of urination there will almost always be an admixture 
of germs from the meatus of the urethra and the glans, which may 
eventually spoil the urine. 

In order to examine a urine for micro-organisms, the sediment 
maybe employed for direct microscopical inspection or for cultures. 
In the latter case, particular care should be exercised to avoid 
outside contamination. The urine is drawn off by means of a 
sterile catheter into a sterile flask, allowed to settle, and a portion 
of the sediment then transferred upon suitable media by means of 
a sterile pipette. Sometimes it is advisable to keep the urine in an 
incubator for twenty-four hours before making culture, so as to 
allow the germs to proliferate. For simple microscopical examina- 
tion such aseptic precautions are not necessary, as outside con- 
tamination, if present, will be so slight as to escape detection. A 
few drops of the centrif uged sediment are simply spread on a glass 
slide and allowed to dry, the slide is then passed through the flame 
of the Bunsen burner several times until hot to the touch, in order 
to coagulate the albumin and fix the morphological elements so that 
they do not wash off during the subsequent staining. Sometimes 
the urine itself does not contain sufficient fixative, when a drop 
of very dilute egg-albumin must be added. 

In the following conditions a bacteriological examination may 
be necessary for a diagnosis : 

Tuberculosis of the genito-urinary tract. 

Gonorrhea. 

Sepsis. 

Typhoid fever. 
An examination will be desirable, though not essential, in all 
suppurative conditions of the genito-urinary tract or wherever pus 
is present. 

(135) 



136 EXAMINATION OF URINE. 

Tuberculosis. — In tuberculosis of the bladder and kidney, the 
urine frequently contains blood, pus and tubercle bacilli. If the 
lesion is located in the bladder, the entire urine Avill be altered, but 
in unilateral renal disease it is desirable to examine the two sam- 
ples obtained by ureteral catheterization in order to determine the 
affected side. (Plate VII., Fig. 1.) 

In order to demonstrate tubercle bacilli, the urine should be 
drawn off by means of a catheter to avoid contamination with 
smegma bacilli, which resemble the tubercle bacilli in their mor- 
phology and staining properties. Where the urine contains much 
mucus and pus, so that it cannot be well sedimented, a pinch of 
pancreatin and bicarbonate of soda may be added, since this will 
digest the heavy ropy masses in a few hours. 

Tubercle bacilli are stained as follows : The fixed slide or slides 
(in suspicious cases it is always best to prepare three or four) are 
placed on two glass rods, resting on the ring of an ordinary iron 
stand, which must be absolutely level. They are then flooded with 
carbol-fuchsine (saturated alcoholic solution of fuchsine, 10 per 
cent., 5 per cent, carbolic acid 90 per cent., the mixture should 
be at least a day old) and heated directly with the Bunsen burner 
until steam is given off. This is repeated in a feiv minutes, then 
the specimens are allowed to slide into a glass dish by raising one 
glass rod. They are then washed off in water by lifting them from 
the dish with a forceps and then go into 5 per cent, sulphuric 
acid for about half a minute. After washing in water, decoloriza- 
tion is completed by leaving in 95 per cent, alcohol for a few 
minutes. The alcohol is finally washed off and the slides counter- 
stained for a minute or tw T o with very dilute methylene-blue. They 
should be examined with the oil-immersion lens, when tubercle 
bacilli will be readily identified as slender, straight or slightly 
curved rods. They occur singly or two or three individuals lie 
side by side or end to end. While all cells and other bacteria 
appear blue, they alone have retained the red dye. 

As stated above, the smegma bacillus may occasionally appear 
like the tubercle bacillus, and special precautions are necessary, 
as it may even occur in urine directly drawn from the bladder. 
The smegma bacillus is, however, never grouped like the tubercle 
bacillus and never beaded. Furthermore, it is completely decolor- 
ized by leaving the slides in absolute alcohol for five to eight hours 
after they have been in the acid. The staining of the tubercle 
bacillus is not affected by this. Eecently Pappenheim's modifica- 
tion has been recommended, since with it the smegma bacillus is 



PLATE VII. 



FIG. 1. 



/ 



i I K 



Tuberculous Sputum Stained by Gabbett's Method. The 

Tubercle Bacilli are seen as Red Rods, all 

else is Stained Blue. (Abbott. ) 







FIG 


r. 2. 








M 

«■■■■ , r- 


/ 












". 


r 


* -' ,: - 
'■*, 












$ V 




,-l't 


"^'.i 










•&%, * 


' **d& "' 








\ K 


""**» 








: ■A-' ,r :t" > -::>*- 


'•*« 


* "\ 


^* ; 




.$- 







-M 



• rV.;'." T* ' 



\tf 



' /I Jv ..." g% 



; 






■^.?»w .,-* % 



Gonoeoeeus. (Musser.) 



BACTERIOLOGY OF URINE. 137 

less liable to be stained. The slide is prepared the same way and 
then heated with a solution consisting of fuchsine, 1 part. 5 per 
cent, carbolic acid 100 parts, absolute alcohol, 10 parts. The 
excess of staining fluid is drained off, when the preparations are 
immersed from three to five times in Pappenheim's solution, care 
being taken to let the fluid drain off slowly after each immersion.- 
The stain consists of one part of corallin (rosolic acid) in 100 
parts of absolute alcohol, to which methylene blue is added to 
saturation. The mixture is further treated with 20 parts of 
glycerine and is then ready for use. The specimens are finally 
washed in water and dried. The tubercle bacilli will be red, every- 
thing else bine. 

Fig. 60. 



* 


\ 


~ ' s. 


/ 
/ 
/ 



Smegma bacilli, similar in appearance to tubercle bacilli. X K)00 diam. (Park.) 

If repeated examinations by above methods are negative, the 
fresh sediment may be injected into the abdominal parietes of a 
guinea-pig. In from three to six Aveeks the inguinal lymph nodes 
will swell and tubercles will develop in the spleen, liver and other 
internal organs. 

The cultivating of tubercle bacilli is hardly possible with urinary 
sediments, since the slowly-growing bacillus would be rapidly over- 
grown by other germs present. 

Gonococcus. — For the diagnosis of gonorrhea, it is always best 
to obtain a drop of the secretion from the meatus or after massag- 
ing the prostate, since the cocci rapidly die off in the urine. Some- 
times, however, only the urine is at our disposal, when the sedi- 
ment should be dried and fixed as stated above. Tor ordinary 
purposes, a 1 per cent, solution of methylene blue or Jenner's 
stain is best for gonococci, which appear as small, oval, coffee- 
bean shaped granules, grouped as twos or fours within the pus or 
epithelial cells. For more accurate differentiation, Gram's modi- 



138 



EXAMINATION OF URINE. 



fled stain should be used, as follows : The fixed slides are stained 
one to two minutes in 10 parts of saturated alcoholic solution of 
gentian violet to 90 parts of a 5 per cent, solution of carbolic acid. 
Without washing they are then transferred for one to three minutes 
into Lugol's solution (one part of iodine, two parts of potassium 
iodide and 300 parts of distilled water) and again without wash- 
ing into absolute alcohol for about one and one-half minutes, or 
until no more color is given off ; they are then washed and counter- 
stained with Bismark-brown. (Plate VII., Fig. 2.) 

Recently neutral red has been employed for the staining of 
gonococci. A small drop of fresh' pus or sediment is mixed with 
a loop-ful of saturated aqueous solution of neutral red, diluted 
100 times in normal salt solution, and examined in a hanging drop. 



Fig. 61. 



Fig. 62. 



X * 



^ 




Staphylococcus. X 1100 diameters. 
(Park.) 




Streptococci in peritoneal fluid, partly 
enclosed in leucocytes. X 1000 di- 
ameters. (Park.) 



Intracellular gonococci will then be stained deep red, while other 
germs do not take up the dye. 

Chronic gonorrhea often manifests itself by the presence of so- 
called "gonorrheal-threads," consisting of pus cells held together 
in a matrix of mucus. Though undoubtedly gonorrheal in origin, 
it is generally very difficult to demonstrate gonococci in these 
shreds. 

Gonococci are very difficult to grow from urinary sediment, since 
they frequently have died off. From the secretion, however, an 
abundant growth may often be obtained, if it be remembered that 
gonococci require uncoagulated human serum for their propaga- 
tion. It is merely necessary to mix ordinary agar with sterile 
hydrocele or ascitic fluid and to inoculate the surface of a slant. 

In sepsis germs will often be excreted in the urine, especially 



BACTERIOLOGY OF UIUXE. 



139 



when the bacteriological examination of the blood has been nega- 
tive. The organisms which most commonly concern us here are 
staphylococci, streptococci and colon bacilli, less frequently pneu- 
mococci, proteus, etc. Their isolation and identification requires 
the usual bacteriological technique. 

Typhoid Fever. — The examination of urine of cases suspicious 
of typhoid fever is of the greatest importance, since the germs are 
excreted in about 30 per cent, of the cases, and often where the 
Widal and other signs fail. It is true that blood-cultures give as 
high as 80-85 per cent, positive results, but the elaborate technique 
necessary for venepuncture argues against its general use by the 
practitioner. One should not, however, be misled by the mere 

Fig. 63. 




Colon bacilli. Twenty-four-hour agar culture. X 1100 diameters. (Park.) 

presence of motile, Gram-negative bacilli in the urine, since even 
in typhoid fever these will often be colon bacilli. In bacteriological 
laboratories, where all the necessary media are at hand, the quickest 
and safest way of identifying typhoid bacilli in urinary sediment 
is bv means of the method of Drvs'alski-Conradi, originally recom- 
mended for the feces. The liquefied culture-medium (consisting 
of peptone, salt, nutrose, sugar of milk, krystal violet, litmus and 
agar) is poured into three sterile Petri dishes and allowed to 
harden. A loopful is then spread over the surface of plate one 
with a special glass rod; plates two and three are then inoculated 
with the same spreader and all three placed in the incubator. After 
twenty-four to thirty-six hours the colon bacilli will form red, 
opaque colonies, while the typhoid colonies are much smaller, trans- 



140 



EXAMINATION OF URINE. 



parent and blue, like dew-drops. This different behavior is due to 
the fact that the colon bacillus will split up the sugar of milk with 
the formation of acid, which colors the litmus reel, while the 
typhoid germ cannot attack the sugar, but will decompose the 
proteids with the formation of alkali. The suspicious typhoid 

Fig. 64. 










Actinomyces. 

germs may further be tested with an animal immune serum of high 
agglutinating power. 

For the ordinary practitioner, however, this method is too com- 
plicated. There is as yet no simple method to distinguish between 
both germs, since both have the same morphological appearance 




Yeast cells. 



and are Gram-negative. The colon bacillus, however, ferments 
glucose broth, reduces neutral red agar and forms indol, which 
properties are not shared by the typhoid bacillus. 

The germs usually encountered in suppurative disease of the 
tract are the various types of staphylococcus, the 



irenito-urinarv 



BACTERIOLOGY OF IR1SE. HI 

streptococcus and particularly the colon bacillus. The former two 
may be readily identified by methylene blue or by Gram's stain, 
and can be grown on the usual media. 

Actinomyces kernels may be observed in the urine when the 
disease in question has attacked the genito-urinary tract, or when 
the organism has found its way in the urine from other organs. 

Yeasts and moulds are sometimes found in diabetic urines, but 
may also occur in the absence of sugar. 

Urines which have undergone ammoniacal fermentation fre- 
quently contain the so-called Mici'ococcus urece in large quantities. 
This germ forms long chains, like the streptococcus, but the indi- 
vidual members of the chain are considerably larger. It is respon- 
sible for the decompositipn of urea into ammonia. 



CHAPTER X. 

PRESERVATION OF URINE. 
GENERAL ROUTINE EXAMINATION OF URINE. 

A number of drugs have been recommended for the preservation 
of urine, but the best is thymol. A few crystals may be put into 
the bottle, which is given to the patient, and the urine may then 
be kept for a long time before it spoils. Instead of thymol, 
camphor or a few drops of an alcoholic solution of salicylic acid 
may be employed. The great disadvantage of chloroform lies in 
the fact that it settles to the bottom and mixes with the sediment. 
Recently formalin has been recommended, but C. Strzyzowski 1 
concludes that this substance is unsuited since it interferes with 
too many important reactions. Thus, urea will combine with 
formalin to form a leucin-like deposit. Uric acid will also form 
a compound and the indican reactions will be faint or absent alto- 
gether. The behavior toward albumin varies; sometimes traces 
are no longer precipitated on boiling preserved urine. The influ- 
ence upon sugar, pentose, glycuronic acid, acetone, diacetic and 
/^-oxy butyric acid is very slight, while bile-principles may be pre- 
cipitated with the urea, from which they can be dissolved out by 
acid alcohol. Pettenkofer's reaction is no longer possible in the 
presence of formalin. 

No matter ivhat the preservative, especial care must be taken 
with the sugar reaction, and several tests should be used as control. 

For the preservation of organized sediment, the following solu- 
tion is recommended 2 : 

Sodium chloride 1 gme. 

Sodium sulphate 5 gme. 

Mercuric chloride 0.5 gme. 

Distilled water 200 gme. 

The sediment is treated with this solution for twenty-four hours. 
The fluid is then poured off and the sediment washed a few times 
with distilled water. All constituents will appear in their unal- 
tered shape and structure, just as they are found in the urine. To 

1 Therap. Monatshefte, May, 1904. 

2 Pharmac. Centralhalle, 1895. p. 484. 

(142) 



PRESERVATION OF URINE. 143 

prepare specimens, a small amount is taken up with a pipette and 
mounted in glycerine. Instead of above solution, formalin may be 
employed. 

With every sample of urine obtained by the physician, the color, 
transparency, reaction and specific gravity should be noted. About 
30 c.c. are then filtered through paper, if necessary with the aid 
of talcum, Fuller's earth, magnesia or charcoal. The rest is set 
aside in a conical glass and allowed to sediment. The filtrate is 
distributed among three test-tubes: (a) a large one which is filled 
about one-sixth full, (b) a medium-sized one, filled about two- 
thirds, and (c) a small one, filled about one-fourth. To (a) about 
one-tenth of Nylanders solution is added. A black precipitate on 
boiling = sugar ; (b) is boiled only in its upper portion ; a precipi- 
tate which is dissolved on the addition of a few drops of acetic 
acid = excess of phosphates; a precipitate or turbidity which does 
not dissolve, but becomes more distinct on the addition of acetic 
acid = albumin. If the turbidity is at all marked, or an actual 
precipitate has formed, some urine should be filtered into an 
Esbach tube up to the mark IT, then Esbach's reagent up to R. 
After shaking, the tube is set aside for twenty-four hours, when 
the amount of precipitate = percentage of albumin. To the urine 
in test-tube (c) (which must be' acidified with acetic acid, if not 
normally acid) a pinch of sulpho salicylic acid is added ; a turbidity 
or precipitate will be referable to albumin, and will serve as control 
|est for the heat and acetic acid reaction. It is always well to 
gently heat this test-tube if the reaction was positive, as urates and 
albumoses, which may also be thrown down, will then dissolve, 
while the albumin precipitate will become more pronounced. 

Whenever the Xylander test is positive, other tests should be 
employed as control, as many substances other than sugar also give 
a partial or complete reaction. A portion of the urine (unless 
very pale) is then precipitated with lead acetate, filtered and 
polariscoped, another portion is mixed with fresh yeast and poured 
into the Lolrnstein saccliarometer (the inaccurate Einhorn instru- 
ment should be entirely discarded). Dextrorotation in the polar- 
i scope and the formation of carbon-dioxide gas in the saccha- 
rometer, are positive proof that sugar is present and furthermore 
enable a quantitative analysis. The amount of sugar may, how- 
ever, be so small that both tests give doubtful results, then recourse 
should be had to the plienylliydrazine test. When a polariscope 
is not at hand, and a rapid result is desired, the urine may be 
titrated with Fehling's or Budiscli's solutions. Where Xvlander's 



ItW: examination of urine. 

reaction is partially or completely positive, but the other tests 
enumerated above, all or in part negative, the following principles 
may be present : 

Albumin, owing to the formation of bismuth sulphide. The albumin 
should first be removed by boiling the acidified urine and filtering. 
Pentose — detected by orcin test. 

Drue's— 110 ACld ~~\ The patient's history should be investigated. 
Ghrysophahic acid. — The patient has taken rhubarb, senna, cascara, 

etc., and the urine is usually dark red. 
Melanin. — Urine is dark or becomes dark on exposure and reacts 

positive to special tests for melanin. 
Hydrogen sulphide. — Detected by odor and special test. 

The following table will show, in a general way, when it is desir- 
able to test for other principles : 

1. Chlorides — 

Pneumonia and other acute febrile diseases (proportionate to 
the general severity of the case and often when exudates 
form. At the crisis and often a few hours before the appear- 
ance of other symptoms of improvement, the chlorides are 
sharply increased. 

Acute and chronic renal disease (diminished). 

Carcinoma of stomach (diminished). With the resorption of 
exudates and transudates (increased). 

To detect digestive power of patients (10 — 15.0=normal, less 
=below normal) . 

2. Phosphates (rarely required) — f 

Pneumonia and acute infectious diseases, acute and chronic 
nephritis, like chlorides, phosphatic diabetes (increased). 

3. Sulphates (rarely required) — 

Acute febrile diseases (increased, but decreased during con- 
valescence ) . 

Conjugate sulphates increased in intestinal putrefaction from 
coprostasis, due to carcinoma of the intestines, with dimin- 
ished excretion of acid in stomach and in obstructive jaun- 
dice. 

Neutral sulphur increased in cystin diathesis. 

4. Urea and Total Nitrogen — 

Diseases of liver (acute yellow atrophy, cirrhosis, carcinoma 
(diminished) . 

Diseases of kidney (especially where tubules are affected), 
(diminished) . 

Acute febrile diseases, especially those ending by crisis (in- 
creased). 

Diabetes mellitus (increased). 

Conditions associated with dyspnea (increased). 

Congestion of kidneys with concentrated urine (increased). 

5. Ammonia (rarely required) — 

Acute yellow atrophy and other hepatic disease, phosphorus 
poisoning, fevers, dyspneic conditions and diabetes (in- 
creased) . 

Nephritis ( diminished ) . 

6. Uric Acid and Nanthin Basis — 

Gout (increased before the attack, diminished after; often 
inconstant) . 

Leucemia and other diseases associated with leucocytosis (in- 
creased) . 

Nephritis (diminished). 



PRESERVATION OF URINE. 145 

7. Album ose — 

Where there is accumulation with more or less absorption of 

pus in the body. 
Ulcerative lesions of the intestines. 
Scurvy, pernicious anemia, leukemia and other disorders of 

blood. 

8. Bence Jones Albumin — 

When there is suspicion of multiple bone tumors. 

9. Hemoglobin — 

With dark color of urine, after ingestion of poisons and with 
severe infectious diseases. 

10. Indican — 

Carcinoma of the stomach and gastric conditions associated 
with hypo or anchlorhydria. 

In obstruction of the small intestines (not in simple constipa- 
tion) . 

In empyema, putrid bronchitis or gangrene of lung. 

11. Skatoccyl — like indican. 

12. Rosenbach Reaction — like indican. 

13. Phenol— 

Like indican and after poisoning with carbolic acid and allied 
compounds. 

14. Bile— 

Where color of urine is dark brown, especially if foam is 

colored. 
Diseases of liver, pancreas and bile ducts. 
Severe infections and poisoning. 

15. Urobilin (not important) — 

Pernicious anemia. 

16. Melanin (not important) — 

Where urine is dark in color. 
In suspected melanotic tumors. 

17. Alkapton (not important) — 

Where urine is dark in color. 

18. Diazo reaction — 

Typhoid, miliary tuberculosis. 
Measles. 

19. Ehrlich's Dimethylamidobenzaldchyde Reaction — 

Wherever there is increased katobolism of tissue albumins, 
especially in tuberculosis. 

20. Acetone — 

Diabetes ( especially before coma ) . in prolonged fevers, in preg- 
nancy and conditions of cachexia, especially carcinoma of 
stomach. 

21. Diacetic Acid — like acetone. 

22. fi-oxybutyric Acid — like acetone. 

23. Leucin and Ty rosin — 

In diseases of the liver, notably in acute yellow atrophy. 

24. Cryoscopy — 

In renal disease, wherever there is suspicion of renal insuffi- 
ciency. 

When the chemical examination is completed, the sediment 
should be collected, centrifuged and examined on a slide with a 
cover-slip. Where a bacteriological' examination is also required, 
a portion of the centrifuged sediment is spread out as thin as pos- 
sible on a slide, allowed to dry, fixed and stained as described in a 
previous chapter. 



146 EXAMINATION OF URINE. 

Calculi or gravel, if present should be collected on a filter and 
subjected to a chemical analysis as described in Chapter VII. 

After ureteral catheterization, or with infants, only small quan- 
tities of urine may be available. With only 5 c.c. the procedure 
would be as follows : The entire quantity is first centrifuged, and 
a small amount of the sediment removed and examined micro- 
scopically and, if necessary, bacteriologically. After the color, 
appearance and reaction have been noted, the specific gravity is 
determined by means of Saxe's instrument (page 32). The entire 
quantity is then taken and divided into two halves, one for the 
Nylander sugar test, the other for the determination of albumin. 
The ring test is preferable here, since it will also give an approxi- 
mate idea as to the presence and amount of indican, bile, etc., 
present, Should the observation of E. Reiss 1 be true, that by 
means of the refractometer, the amount of albumin can be deter- 
mined in a single drop of fluid, this instrument may find a welcome 
place in laboratories. If any other special tests are required, the 
urine should be divided into three equal parts and examined in 
small test-tubes. With less than 5. c.c. the urine must be diluted, 
though the results will then be less accurate. 

1 Arch. f. exp. Path. u. Pharmak., vol. 51, No. 1. 



CHAPTER XI. 

FUNCTIONAL EFFICIENCY OF KIDNEYS. 

It is often desirable and even necessary to determine if the 
amount of kidney tissue present is compatible with life. In cases 
of nephritis with or without uremia, a prognosis may be desired, 
or in surgical affections of the kidney there may be indications for 
removing one organ. Until a few years ago the physician had as 
his only means such knowledge as was offered by a routine exam- 
ination of the urine, notably the estimation of urea and total 
nitrogen present. The surgeon was -often obliged to expose the sup- 
posedly healthy kidney and to determine its functionating power 
by such crude methods as palpation and inspection. A great 
advance was noted when methods came into use which permitted 
a separate collection of the urine from both organs. The various 
segregators recommended are imperfect and hardly ever employed 
at the present day, but in cystoscopy, by Kelly's direct method, 
or with one of the more complicated cystoscopes we now have a 
method which permits of the direct catheterization of both ureters. 
It is evident that much valuable information can be gained by a 
separate examination of both urines, but where the disease affects 
both organs, other methods must be resorted to. 

1. Estimation of urea or of total nitrogen. The ordinary 
clinical methods lack accuracy, and the better methods require time 
and skill in chemical analysis which the practicing physician may 
not possess. But even if exact data are at hand, the amount of 
nitrogen has been found to vary within such wide limits during 
health, that it is impossible to draw a dividing line between suffi- 
cient and insufficient function. The character of the food plays 
an important part, but even with an accurate control over what is 
ingested, marked irregularities in the rate of excretion are some- 
times observed which may be of no pathological significance. The 
same sources of error are present in results based upon the quanti- 
tative determination of the total salts, or what is more convenient, 
the total chlorides of the urine. There seems to be no constant 
ratio between the kidney efficiency and the quantity of chlorides 
excreted. 

(147) 



148 EXAMINATION OF URINE. 

2. Determination of the amount and rate of excretion of sub- 
stances injected into the blood. Formerly .05 grammes of methy- 
lene blue were injected into the gluteal musculature. After a cer- 
tain time, the dye appears in the urine, partly as such, coloring 
the urine green, and partly as its chromogen, which is converted 
into the pigment by boiling the urine with acetic acid. Certain 
definite rules have been laid down concerning the time which 
elapses before the dye appears in the urine and its rate of excretion. 
Recent investigations, however, have shown that both are very in- 
constant, and that figures approximately accurate can only be given 
for chronic interstitial nephritis. These limitations, together with 
the difficulties encountered in the estimation of the amount ex- 
creted, have prevented the general application of the method. More 
recently F. Yoelker and E. Joseph 1 claim to have discovered an 
ideal dye to replace methylene-blue, in indigo-carmine. Injected 
in doses of 16 centigrams into the gluteal muscles, it is absolutely 
harmless and possesses the further advantage of being excreted 
solely by the kidneys. The excretion is absolutely uniform ; with 
normal kidneys it begins in fifteen to thirty minutes, reaches its 
maximum after two hours, and then gradually disappears during 
the next ten hours. An accurate study of the action of both kidneys 
is possible, even in cases where one cannot find the ureteral orifices, 
and truly beautiful pictures are obtained with the cystoscope. The 
method fails only in cases of prolapsed uterus and vagina, since 
here the discharge of urine is into a cul-de-sac behind a prominent 
bar of tissue and, hence, invisible to the eye. One great value of 
the method lies in the fact that the actual amount of functionating 
tissue in each kidney can be determined by observing the frequency 
of contraction and the size and color of the blue cloud which rises 
in the colorless fluid. 

Phloridzine has also been injected, since this permits normal 
kidneys to excrete sugar. If 0.05 to 0.01 gramme is introduced 
subcutaneously, glycosuria will begin fifteen to thirty minutes later 
and last about three hours. Caspar and Richter do not pay much 
attention to the beginning and duration of excretion, but believe 
that the amount of sugar found is alone of importance. In normal 
cases, both sides excrete approximately the same amount, but if 
one kidney is diseased, considerably less sugar will be voided. 
Israel disputes these observations, and states that the excretion is 
never uniform on both sides, even in health, and that errors up to 
30 per cent, still belong within physiological limits. 

1 Munch, mod. Woch., Dec. 1, 1903. 



FUNCTIONAL EFFICIENCY OF KIDNEYS. 149 

3. Cryoscopy. — The principles underlying cryoscopy have al- 
ready been described in Chapter II. It is impossible at this date 
to pass a final opinion as to the value of the method and further 
observations are necessary. H. Kummel and O. Rumpel 1 have 
resorted to cryoscopy in over 300 cases, and come to the following 
conclusions : With intact kidneys, the molecular concentration of 
the blood is a constant figure and corresponds to a freezing point 
of 0.56° C. In bilateral renal diseases, the molecular concentra- 
tion of the blood is increased and the molecular concentration of the 
urine diminished, hence the freezing point of the former 4 is lower, 
and of the latter higher, and more near to that of water. Unilateral 
renal disease does not cause general disturbance which would 
increase the molecular .concentration of the blood. Unilateral 
disease can be readily detected by means of ureteral catheteriza- 
tion. The urine from the affected side will show diminished 
molecular concentration and a reduced amount of urea, while that 
of the healthy side will be normal. Renal diagnosis is furthermore 
aided by the Roentgen rays, since all stones will throw a distinct 
shadow. 

These observations do not agree entirely with those of Israel. 2 
This author states that the cryoscopy of blood gives a clear idea 
of renal function in a limited number of cases only, since tumors 
and other conditions may also change the freezing point. In 
nephritis, a marked hydremia may compensate for the depression, 
so that approximately normal figures are obtained. In discussing 
the phloridzine method, Israel expresses equally pessimistic views, 
since he does not believe that there is any relation between the 
sugar excreted and the amount of normal renal tissue left. 

TOXICITY OF THE URINE. 

Since the function of the kidneys consists in removing waste 
products from the organism, it is but natural to conclude that every 
normal urine possesses toxic properties. The first observations 
were brought forward by Feltz and Ritter, who made injections of 
unaltered urine, which were followed by the animal's death. Some- 
what later, Bouchard discovered that 10-15 c.c. of urine for each 
kilogram of the animal will bring about intense contraction of the 
pupils, increased, shallow respirations and somnolency. An in- 
creased amount of urine is voided, the body-temperature falls, the 

2 Bertrag. z. klin. Chirurg., vol. 37, No. 3. 

2 Mitt a. d. Grenggebiete d. Med. u. Chirurg.. vol. 11. Xo. 2. 



150 EXAMINATION OF URINE. 

reflexes are diminished and the eyeballs frequently protrude. 
Death soon comes on without convulsions, and sometimes the pupils 
dilate shortly before death. Smaller amounts cause less intense 
symptoms, and in about half an hour the animal may again appear 
normal. The amount of urine necessary to kill a kilogram of 
animal is termed by Bouchard a "urotoxy." The toxicity varies, 
however, even under normal conditions; thus, the night urine is 
only half as poisonous and may set up convulsions. Muscular 
exercise will also lower the toxicity. Many experiments have been 
conducted with a view of determining the poisonous principle, but 
these have all been unsuccessful, probably because not one but 
many ingredients are responsible for the symptom-complex. Thus, 
Bouchard speaks of seven distinct bodies, viz. : 1. An organic 
diuretic substance which is not destroyed by heat or removed by 
carbon. This is probably identical with urea. 2. An organic 
narcotic substance, not fixed by carbon and of unknown composi- 
tion'. 3. An unknown sialogogue principle. 4. An organic, con- 
vulsive substance of alkaloidal nature, especially abundant in night 
urine. 5. An organic substance which causes contraction of the 
pupils. It seems to be one of the pigments in urine. 6. A body- 
heat-reducing principle, which is probably also pigmentary in 
nature. 7. Other convulsive principles, slower in action. These 
are probably the salts of potassium. It seems strange that despite 
the most accurate analysis of urine, only two of all these substances 
should be known. The influence of alimentation and labor on the 
toxicity of urine, has been carefully studied by Casciani, 1 who 
finds that: 1. Persons working but little and living on a strictly 
vegetable diet, excrete a urine almost free from toxic properties. 
2. In persons resting, urinary toxicity is greater where the indi- 
vidual lives on a mixed diet, and smaller with a vegetable diet. 3. 
A meat diet increases toxicity in direct proportion to the quantity 
ingested. 4. The influence of labor is greater than that of food ; 
this is the more pronounced, the more continuous and excessive 
the work. 5. Excessive meat diet and excessive work cause each 
hypertoxicity of the urine and may produce phenomena of autoin- 
toxication. 

In pathological conditions the urine may be diminished or in- 
creased in toxicity. Thus, in nephritis and uremic states, very 
large amounts may be injected into rabbits with impunity, while in 
fevers the urine may be intensely poisonous and generally shows 

*La Biforma Medica, 1897. 



FUNCTIONAL EFFICIENCY OF KIDNEYS. 151 

more convulsive and less narcotic properties. Other conditions 
with very toxic urines are jaundice and liver diseases, malignant 
tumors, pleurisy. Various alkaloidal substances have been isolated 
from the urine in many of these conditions and it is a significant 
fact that the injected animals often present the same symptoms as 
the patient, especially as far as the nervous system is concerned. 
Various toxic principles have also been discovered in the urine of 
epilepsy, diabetes, Basedow's and Addison's disease. 

Though the literature on the subject of urinary toxicity is very 
large, the practical results obtained are very small, so that this 
branch of urinalysis has come into disfavor and is but rarely prac- 
ticed at the present day. The relations between toxicity and 
etiology of disease have been grossly exaggerated by Bouchard and 
his followers, and the presence of many of the poisonous alkaloids 
has not been confirmed by others. In its narrow field of usefulness 
the method has been replaced by other, better ones, and the physi- 
cian will only rarely have occasion to inject urine into animals. 



CHAPTEE XII. 

URINARY DIAGNOSIS. 
URINE IN RENAL DISEASE. 



Acute Ne- 
phritis. 



Diminished : Pale red or 
dark red, 
turbid. 



Congestion of Diminished 
Kidneys. 



Increased, i Abundant. 



Chronic Par- 
enchymatous 
Nephritis. 


Somewhat 
diminished 


Se c o n dar y 
Contracted 
Kidney. 


Normal or 
increased. 


Primary In- 
terstitial 
Nephritis . 


Very 
abundant. 


Amyloid Kid- 
ney. 


Normal or 
increased. 



Moderate am't [Generally 
varying- con- absent. 

siderably. | 



Pinkish, Normal or | Abundant. Generally 

turbid. increased. > present 



Pale, yel- 
lowish. 



Slightly di- Moderate, 
minished. 



Diminished j Scant. 



Normal or [ Abundant, 
diminished 1 rarely absent 



Often a 
slight am't. 



Generally 
absent. 



Red and white 
blood cells, 
casts of all 
kinds, urates. 

Few red blood 
cells, hyaline 
casts, urates. 



Red and white 
blood cells, 
casts of all 
kinds. 

Many casts of 
all kinds. 



Generally only 
hyaline casts. 



F e w hyaline 
and granular 
or waxy 
casts, few 
leucocytes. 



Urea and 
Salts. 



Urea, chlo- 
rides and 
phosphites 
reduced. 

Absolute 
amount of 
urea slightly 
diminished. 
Chloride s 
normal. 

Diminished 
excretion of 
urea and 
salts. 

Dim inished 
excretion of 
urea and 
salts. 

Urea and salts 
much re- 
duced. 

Generally nor- 
mal. 



URINE IN OTHER CONDITIONS. 

Fevers.— Dark, of increased acidity and specific gravity. 
Oliguria at first, followed by polyuria during convalescence. Urea, 
uric acid and sulphates increased, chlorides and phosphates dimin- 
ished. Sometimes acetone is present and in very severe infections, 
hemoglobin or bile pigment. In typhoid, tuberculosis and measles, 
the diazo reaction. 

Tumors. — Sometimes acetone present, and in carcinoma of the 
stomach, indican excessive. 

Diseases of Stomach. — In an- and hypochlorhydria, indican, 
skatol and phenol increased. In an- hypo- and hyperchlorhydria, 
chlorides diminished. 

Diseases of Intestines. — In obstruction of small intestines 
and increased intestinal putrefaction, indol, skatol and phenol in- 
creased. In ulcerative lesions, albumose sometimes present. 

(152) 



URIXARY DIAGNOSIS. 153 

Diseases of Liver. — Bile if severe, or biliary passages ob- 
structed. Urea diminished and with serious lesions (acute yellow 
atrophy, etc.), ammonia increased and leucin and tyrosin present. 

Diabetes Mellitus. — Pale, of high specific gravity, dimin- 
ished acidity and increased in amount. Urea, phosphates and 
ammonia increased, chlorides and other salts diminished. Glucose 
and sometimes other sugars present, in severe cases, acetone, di- 
acetic, /?-oxybutyric and a-crotonic acids. Urine may possess 
property of dissolving gentian violet. 

Diabetes Insipidus. — Pale, low specific gravity, increased amount. 
Urea, chlorides and other salts diminished. 

G-out.— Acidity increased, uric acid and xanthin bases increased 
or diminished. 

Leucemia. — Uric acid and xanthin bases increased. 

Suppurations-. — Indican increased, albumin present, chlorides 
often diminished. 

Bone Tumors (especially multiple myelomata). — Sometimes 
Bence-Jones bodies. 

Cystitis. — Urine faintly acid or alkaline, contains mucus, pus 
cells and bacteria. 

Pyelitis. — Urine generally acid, contains less pus than in cystitis, 
and may show caudate cells. 

Suppurative Nephritis. — Urine may contain pus, pus casts and 
sometimes bacterial and other casts. 



CHAPTER XIII. 



REAGENTS NECESSARY FOR URINALYSIS. 



Acetic acid mixture (phosphates) 

Sod. acetate, 100 

Acid acetic, 30 

Water to make 1000 
Acid acetic glacial, 50%, 10% and 2%. 
Acid betanaphthol sulphonic 
Acid hydrochloric 
Acid indigotin disulphonic 
Acid metaphosphoric 
Acid nitric c.p. 
Acid nitric, fuming 
Acid nitrous-sulphuric (uric acid) 

Acid sulphuric c.p. 25 c.c. 

Acid nitric, fuming, 1 c.c. 

Water, 75 c.c. 
Acid orthonitrophenyl propiolic 
Acid paradiazo benzolsulphonic 
Acid picric 

Acid phosphomolybdic, 10% 
Acid phosphoric 
Acid phosphotungstic, 10% 
Acid rosolic 1% alcoholic solution 
Acid sulphosalicylic, substance and 12.5 

% solution 
Acid sulphuric, concentrated and 5% 
5=48.91 gme to litre 
5=24.46 gme to litre 
^ 4.89 gme to litre 
Acid tannic 
Acid trichloracetic 
Albumin 

Alcohol, 95% and absolute 
Alcohol amylic 
Alizarin 
Ammonia water 

Ammonia-ferric alum (sat. solution) 
Ammonia-carb. 

chlor. 

molybd. 

oxalate 

sulphate, cryst. and sat. sol. 



B. 



Barium chloride, sat. sol. 

Barium hydrate 

Barium mixture 

Barium chloride, 10 
Caustic baryta, 3-4 

Benzoyl chloride 



Bial's reagent (pentose) 
Orcin, 0.5 

liq. feri sesquicklor, 10 drops 
Acid muriat. cone, 250.0 
Bismark brown, 1% aq. solution 
Bromine water 
Briicke's reagent (sugar) 

1.5 gme. fresh bism. subnitr. 
heated to boiling with 20 c.c. 
water. Add 7.0 gme. potass, 
iodide and 1.5 • gme. hydro- 
chloric acid 



Calc. carbonate 

Calc. chloride 

Calc. oxalate (1-1000) 

Cane sugar 

Carbol. gentian, violet 

sat. ale. sol. gent, violet, 10 
5% carbolic acid, 90 

Carbon disulphide 

Charcoal 

Chloroform 

Copper spiral 

Copper sulphate. 1% and 10% 



Dimethyl amidobenzaldehyde, 2% 
solution 

E. 

Echt-gelb, 1% aqueous solution 
Ehrlich's solution (diazo) 

(a) Acid sulfanilic, 1 
Acid hydrochloric, 5 
Water to make 100 

(b) Sod. nitrite, 0.5 
Water to make 100 

Esbach's solution (albumin) 

Acid picric, 10 

Acid citric, 20 

Water, 1000 
Ether 

F. 

Fehling's solution (sugar) 

(a) Copper sulphate, 34.369 
Water, 500 

(b) Rochelle salts, 173 
Caustic potash, 125 
Water, 500 



(154) 



REAGENTS NECESSARY FOR URINALYSIS. 



155 



Fibrin 
Fuller's earth 



G. 



Glycerine 

Gram's solution (bile) 
Iodine, 1 
Potass, iod, 2 
Water, 300 

Gunning's solution (nitrogen) 
Acid sulphuric cone., 15 
Potass, sulphate, 10 
Copper sulphate, 0.5 



H. 



Hydroxylamine hydrochlorate 



I. 



Iodine, crystals and « 1(l solution = 

112.653 gme. to litre 
Iron chloride, substance and official 

solution 
Iron sulphide 



Magnes. sulphate, sat. sol. 

Magnes. usta 

Magnes. wire 

Maschke's reagent (sugar) 

Sod. tungstate, 30 

30% acetic acid, 75 

Aq. dist. water, 120 
diethyl orange 
Mercury bichloride, 10% and sat. 

solution 
Mercury oxide, freshly precipitated 
Methylene blue 
Millon's reagent (phenol) 

Mercury, 1 

Fuming nitric acid, 1 

Water, 2 



N. 
Xapthol 

Neutral-red, sat." aqueous sol. 
Nylander's solution (sugar) 

Bism. subnitr, 2 

Rochelle salts, 4 

Sodium hydrate, 10 

Water, 90 (boiled and filtered) 



Jenner's stain (eosinate of methylene 

blue) 
Jolles' reagent (albumin) 

Merc, bichlor, 10 

Acid succinic, 20 

Sod. chloride, 10 

Water, 500 
Jolles' reagent (bile) 

(a) Iodine, 0.63 
Alcohol, 125 

(b) Merc, bichlor, 0.75 
Alcohol, 125 

Mix (a) + (b) and add 250 pure 
hydrochloric acid 



Lead, acetate, substance and cone. 

solution 
Lead foil 
Lime, chloride of 
Lime, milk of 
Liq. plumbi subacet. 
Lugol's solution, see Gram's solution 

M. 

Magnesia, milk of 

Magnes. ust, 1 

Water, 12 
Magnesia mixture (xanthin) 

Magnes. sulphate, 1 

Amnion, chloride, 2 

Aq. ammonia, 4 

Water. 8 



0. 



Obermayer's reagent (indican) 

. 2 — 1000 solution of iron ses- 

quichloride in concentrated 

hydrochloric acid 
Oil of turpentine (ozonized) 



P. 

Pancreatin 

Pappenheim's solution (staining) 

Fuchsine, 1 

5 % acid carbolic, 100 

Absol. alcohol, 10 
Para-amido-aceto-phenon 
Phenol phthaleine, 1% ale. sol. 
Phenylhydrazine hydrochlorate 
Phenylhydrazine oxalate 
Phloroglucin 
Platinum foil 
Potass, carb. 
Potass, chrom., 10% sol. 
Potass, ferrocyanide, 10% sol. 
Potass, iodide, n/ 50 sol. 

3.32 gme. to 1 litre 
Potass, nitrate 

Potass, permang., n ' 20 = 1-576 to 1 
litre 

Crystals and 0.30 °/ 
Potass, platinocyanide 
Potass, sulphocyanide «/ 50 sol. = 
1.939 gme. to 1 litre. For chlorides 
= 6.6 to 1 litre 
Pvridine 



156 



EXAMINATION OF URINE. 



R. 

Resorcin 

Rudisch's solution (sugar) 
Copper sulphate, 4.78 
Sodium sulphate, 50 
Sodium carb. cryst., 80 
10% ammonia ad., 500 

Ruhemann's solution (uric acid) 
' Iodine, 1.5 
Potass, iodide, 1.5 
Absol. ale, 15 
Water, 185 



Sodium nitroprusside, 5% sol. 
Sodium throsulphate 

n/i sol. =24.7 64 gme. to litre 

n/j sol.= 2.4764 gme. to litre 
Sodium tungstate 
Spiegler's reagent ( albumin ) 

Merc, bichlor, 8 

Acid tartaric, 4 

Glycerine, 20 

Distilled water, 200 
Spirits of ammonia, 10% 
Starch 



Silver nitrate, 10%; 30% 1 Vio= 
16.955 gme. to 1 litre. n/ 50 '(Ru- 
disch) = 3.3932 silver nitr., 75. aq. 
ammonia sp. gr. 0.9, 10.0 am. 
chloride, water to make 1000. 

for chlorides — 29.059 gme. to 
litre 
Sod. acetate (sat. sol.) 
Sod. bicarbonate 
Sod. carbonate 
Sod. chloride (sat. sol.) 
Sodium hydrate sp. gr. 1.16 and 1.34 
n/j sol. = 39.96 to litre , 
n/ sol. = 19.98 to litre 



n/ 4 SOl,= 
i/j p sol,= 



9.99 to litre 
3.996 to litre 



Sodium hypobromite solution (urea) 

Bromine, 5 c.c. 

30% by volume sod. hydrate, 
70 c.c. 

Water, 180 c.c. 
Soda lime 
Sodium nitrite. 1% solution 



Talcum 
Thymol 
Tinct. Guaiac 



T. 



U. 



Uran. 
Uran. 



acetate 
nitrate, 



Xylidin 
Yeast 



44.78 to litre 
X. 

Y. 

Z. 



Ziehl's solution (staining) 
Sat. ale. sol. fuchsine, 10 
5% carbolic acid, 90 

Zinc c.p. 

Zinc acetate, 10% sol. in abs. ale. 

Zinc chloride ale. solution, spec. grav. 
1.20 



THE FECES. 



CHxVPTEK XIV. 

MACROSCOPIC EXAMINATION OF THE FECES. 

Frequency. — The "normal" frequency of defecation is as little 
capable of exact definition as is the amount, depending, as it does, 
both on idiosyncrasy and a number of other variable factors. The 
amount of fecal residue, its character, whether irritant to the motor 
functions of the gut, or not, and, reciprocally, the condition of 
neuro-muscular mechanism of the lower extremity of the intestinal 
canal, all play an important role. It is highly probable that the 
inflammatory exudations of intestinal disease, together with the 
products of the bacterial agents, exercise a markedly irritant effect, 
with the production of frequent stools. On the other hand, 
psychical, general nervous, and reflex nervous impulses are also 
important elements. The diarrhea of fear, and of such diseases 
as Basedow's, are an example of the former, while it is well known 
to what an extent even slight local lesions of the rectum, such as 
an ulcer or a fissure, may impose as irritative diarrheas. Consti- 
pation, likewise, may be due to a variety of lesions in the neuro- 
muscular apparatus. For example, to tabes, melancholia, lesions 
of the cord, or atony of the musculature. These are all conditions 
which may produce symptomatic disturbances of the defecating 
function, which may be of enormous import for the life and health 
of the patient. 

It has been stated that at the one extreme two stools daily, and 
one stool every forty-eight hours, at the other, may be regarded 
as the normal limits, but this statement is very arbitrary, and it 
is certainly wiser to take the general condition of the patient as a 
guide to the sufficiency of defecation. Certain individuals would 
suffer from copremia under conditions which to others are highly 
satisfactory. 

(157) 



15S EXAMINATION OF TEE FECES. 

Duration of Passage. — Of great importance, not only in con- 
nection with a quantitative estimation of the fecal residue after 
a certain form of diet, but as a purely clinical datum, is the deter- 
mination of the period of time occupied by the passage of the food 
from mouth to anus. 

Strauss, using a diet of 100 grammes of scraped beef, found 
that it passed through the canal on an average in ten to twenty 
hours; in case of "constipation of the small intestine," in sixty 
hours. Maurell, using a pure milk diet, gives as a normal period 
thirty-six to forty-eight hours. Koziczkowsky, with another form 
of diet, gives fifteen to twenty-five hours. 

The importance of an accurate determination of this period lies 
in the fact that so-called diarrheas are indicative very often of 
purely colonic disorders, while simultaneously the small intestine 
may be normal, or may exhibit a very sluggish peristalsis. Thus 
very important information may be gained as to localization of a 
pathological condition. If, in cases of diarrheas, it be found that 
the transition period is approximately normal, the evidence points 
definitely to disease of the lower and transverse colon. In making 
the test, it is essential to have an accurate notion of the normal 
period with the test-diet employed. 

Amount. — The amount of the individual defecation is very 
variable, depending on a number of mutually independent factors. 
The stool is composed (1) of the indigestible residue of the food, 

(2) of the undigested, but not necessarily indigestible residue, 

(3) of the secretions contributed by the intestines and their asso- 
ciated glands. The first and second of these factors are by no. 
means synonymous or interchangeable. Among the essentially 
indigestible constituents of the food are to be reckoned small pieces 
of bone, cartilage, tendons, hairs, scales and bones of fish, and 
similar articles, which occur generally as accidental accompani- 
ments of an animal diet. In vegetable food it is chiefly the cellu- 
lose in its various modifications which contributes to the indigesti- 
ble fecal residue. In this category are, of course, to be reckoned 
all lignified or corky elements of vegetables, nuts or fruits. It is 
to be noted, also, that there is a considerable individual margin as 
regards the digestibility of these and similar elements, so that 
there is an insensible gradation between indigestible and undi- 
gested residues. In the latter class comes a large number of food 
stuffs which are generally classed as hard to digest, and which are 
determined in each case largely by personal idiosyncrasy, by the 
varying make-up of the digestive fluids, by the rapidity of peri- 
stalsis, and also by the method of preparation of the food itself. 



MACROSCOPIC EXAMINATION OF THE FECES. 159 

The third named constituent of the feces, the intestinal con- 
tribution, is of greater import than is generally supposed. 

The only method by which an even approximately exact notion 
can be obtained of the constituent of the stool is afforded by the 
examination of the feces of starving individuals. Cetti, who fasted 
for ten days, passed about 22 grammes of stool on the average per 
day. Other estimates made under similar conditions do not vary 
greatly from this figure. It is, however, undoubtedly true that 
under normal conditions, with an intestinal tract actively stimu- 
lated by the presence of a liberal diet, that this quota is three to 
five times as great. The major portion of it consists of the desqua- 
mated epithelia of the intestinal canal and of its excreta, while 
the remnant of the intestinal secretions is in all probability ex- 
tremely small. 

It is then very evident that the amount of the excreta under 
normal conditions is chiefly dependent on the amount and the 
character of the diet, If the latter be rich in indigestible elements, 
notably vegetables, the amount of fecal matter will be proportion- 
ately increased. Moreover, if the food be well prepared, thoroughly 
cooked and nicely divided by mastication, it is apt to leave a far 
smaller residue. If intestinal peristalsis be overactive and tb^ 
food be rushed through the canal more hurriedly than is normal, 
there will, of course, be a far larger amount of undigested tissue 
in the residue. But aside from the nature of the food and its 
rate of progress through the intestinal canal, an extremely impor- 
tant role in the end-result is played by the secretions of the intes- 
tine and its associated glands, both under normal and pathological 
conditions. 

'The digestive functions of the stomach may be said to exercise 
a very small influence on the character of the stool, inasmuch as 
even complete achylia gastrica scarcely modifies its character. 
Except for the digestion of connective tissue it would seem that 
the intestine is fully capable of vicariously replacing all the gastric 
digestive functions. Far different is the case, however, when 
there is any interference with the functions of liver, pancreas or 
intestine, as may be deduced from a consideration of the physi- 
ological activities. The alteration and absorption of fats, carbohy- 
drates and proteids is absolutely dependent on their proper and 
normal action, and in its absence these food elements appear in 
the feces often in very large quantities, and are microscopically 
appreciable. Water, likewise, may fail to be absorbed, and then 
forms a considerable portion of the soft and semi-fluid evacuations. 
Exactly what role is played by the deficiency of absorption it is 



160 EXAMINATION OF THE FECES. 

rarely possible to determine, inasmuch as the two functions gener- 
ally suffer simultaneously and contribute alike to the end-result; 
as for example in amyloidosis or tabes mesaraica (tuberculosis of 
the mesenteric and retroperitoneal lymph nodes). The patho- 
logical contribution of the gut may take the form of pus, mucus, 
blood, fibrin, or a combination of these, and may at times add 
quite considerably to the amount of the fecal matter. 

The diagnostic application of these data is unfortunately not 
as yet very far advanced ; nevertheless the way has been definitely 
pointed to their value in medicine. Schmidt, for example, has 
definitely shown that the fecal matter thrown out after the use 
of his "test-diet" is far greater in case of fermentative dyspepsias 
than under normal conditions. Furthermore, in case of bottle 
infants, observation of the amount of the various fecal constituents 
gives valuable hints regarding the regulation of the diet. 

Amount of Fecal Matter. — The total amount of fecal matter 
which is passed within twenty-four hours may vary enormously. 
It depends entirely, other factors being equal, on the degree of 
preceding activity of the bowels. Thus Lynch has recorded a 
record stool of 20 kilos after an enema. 

The chief factors which determine the amount of feces are: 
1. Quantity and quality of the food. 2. Quantity of digestive 
juices, etc. 3. Condition of the digestive organs. 

1. Quantity and Quality of the Food. — As has been previously 
stated, foods may be distinguished as digestible and as largely indi- 
gestible. The latter leave a lar°:e fecal residue, and also stimulate 
a more active secretion of the intestinal juices, and tend to increase 
the amount of fecal matter, while, in case of the former, the ten- 
dency is just the reverse. With a given form of diet, similarly, 
the amount of fecal matter will necessarily increase with an in- 
crease in the amount taken per ounce. 

In a series of observations made on healthy individuals of vary- 
ing ages by different investigators the following results were 
obtained : 

Amount of feces 
Age Food grammes 

1. Child of one month Breast milk 3.3 

2. (a) Child of two months " " 6.5 

2. (b) Child of three months Cow's milk 51.6 

3. Child of seven months Varying diets 15.56 

4. Child of nine months Cow's milk, with additions 5.9 

5. Child of % to two years Mixed 77.0 

6. Child of four years " 101.0 

7. Child of six years " 134.5 

8. Child of nine years " 117.0 

9. Child of eleven years " 128.0 

10. Adults . . " 131.0 



MACROSCOPIC EXAMIXATIOX OF THE FECES. 



161 



In experiments made by Rubner, it was found that tbe same 
individual under normal conditions yielded 95 grammes fresh 
feces in the twenty-four hours on a diet of 689 grammes of bread ; 
and 109 grammes per day, on a diet of 1,237 grammes. 

As a general rule, it is found that pro kilo of body-weight adults 
form far less fecal matter daily than do the young, as is shown 
by the following table taken from Camerer : 

Amount of feces 

Year Feces Pro. i kilo milk Pro. i kilo body weight 

Grammes Grammes Grammes 

1. Five months 56 35.2 8.3 

2. Eight years 112 51.7 6.3 

3. Sixty-six years 60.4 29.0 0.0 

The form of diet has enormous influence on the quantity of 
fecal matter. Thus, in a table of Biedert's, the feces in children 
fed on — 

a. Breast milk f The feces, in percentages ^ 1.0 — 1.3 % 

b. Artificial diet ■< of the dry residue of > 2.0 — 3.1 % 

c. Very variegated diet (. food, amounted to ) 5.9 — 7.5 % 

A similar basis of reckoning underlies the following table: 





Amount 


Amount of feces in grammes 


Diet 


Fresh 


Dry residue 


Per cent, of 
dry residue 


1— Mixed 

2 — Vegetable .... 

3— Milk 

4— Milk and Cheese . 

5 — Eggs 

6— Meat 

7— White Bread . . 

8— Rice 

9 — Macaroni .... 

10 — Maize 

11 — Potatoes .... 
12 — Brown Bread . . 

13— Peas 

14 — Carrots 

15 — Cabbage .... 


3075 
2050 and 218 

948 
1435 
1237 

638 

695 

750 
3078 
1360 
9598 
5133 
3831 


131.0 

370.6 

174.0 

88.0 

64.0 

64.0 

109.0 

195.0 

98.0 

198,0 

635.0 

815.0 

927.1 

1092.0 

1670.0 


34.0 

40.6 
27.4 
13.0 
17.2 

28.9 
27.2 
27.0 
49.3 
93.8 
115.8 
124.0 
85.0 
73.8 


25.9 

23.0 
31.1 
20.3 
26.9 
26.5 
13.9 
27.5 
24.9 
14.7 
14.2 
13.4 
7.7 
4.4 



It is evident, therefore, that the form of diet influences the 
quantity of fecal matter to an enormous extent; those elements 
which contain a very small indigestible residue (meat, eggs, cheese, 
white bread, etc. ) give a fecal residue which falls below the normal 
average, while this is exceeded again in diets rich in cellulose. 

2. Quantity of Material Contributed by the Intestinal Tract. — 
This is the second factor of importance. It is an extremely diffi- 



162 EXAMINATION OF THE FECES. 

cult matter to estimate this factor with anything approaching to 
accuracy. The feces of fasting individuals represent, of course, 
simply and solely this element, but the same calculation cannot be 
transferred to the feces of individuals on a regular diet. During 
starvation, various calculations have yielded from 2-6 grammes 
of dried residue of the feces passed within twenty-four hours. 
Schmidt and Strasburger estimate that on an animal diet, free 
from indigestible residue, the dry residue of the daily feces amounts 
to 13-17 grammes, of which the major part is contributed by the 
intestinal tract and by the bacteria. 

3. Condition of the Digestive Organs. — It has already been 
pointed out that deficiency in the digestive juices, by failure prop- 
erly to act upon the food, may increase the daily amount of feces. 
The same holds true of anomalous conditions of peristalsis and 
of absorption. Pathological conditions associated with the excre- 
tion of large masses of pus, mucus, etc., notably alter the amount 
of fecal matter. 

Form and Consistence. — The consistency of the fecal mass is 
chiefly determined by the amount of water which it contains. 
This is not invariably the case, inasmuch as certain forms of thin, 
or gruel-like, stools owe their softness not to water, but to an ab- 
normal amount of fats, mucus or swollen vegetable constituents. 
Microscopical examination, or even, as a rule, careful inspection, 
suffices to differentiate these conditions. An increase of fluid in 
the stools may be due either to exudation or transudation from the 
mucous membrane, or to deficient absorption. It is extremely 
important, but not always easy, to differentiate between these con- 
ditions. If the fluid stool contain other evidences of inflamma- 
tion, such as pus, mucus or blood, it is fair to regard the fluid as 
part of the exudate. The absence of these accompaniments does 
not, however, exclude an exudative origin, inasmuch as they may 
have undergone digestion. In this case one thinks either of transu- 
date or of deficient absorption. If the fluid stools contain many 
epithelia, especially in shreds or flakes as in cholera, the proba- 
bility is strong that there has been transudation through the de- 
nuded w T all of the gut. On the other hand, the presence of large 
amounts of undigested food particles, especially fat or muscle, 
argues for absorptive disturbances, not necessarily, however, for 
organic disease. Thus, increased peristalsis for any cause, whether 
nervous or due to the nature of the diet, suffices to produce a watery 
stool through failure of absorption. In the absence of colic, how- 



MACROSCOPIC EXAMINATION OF THE FECES. 163 

ever, and of inflammatory products, a watery stool rich in undi- 
gested food elements argues for organic disease, notably amyloid- 
osis or tabes mesaraica. 

Delayed peristalsis, with a prolonged sojourn in the colon and 
rectum, lead to excessive absorption of water, with the formation 
of an extremely hard fecal mass, formally the stool is conical 
and of a certain medium, uniform caliber. In constipation, how- 
ever, it is apt to become considerably larger and irregular through 
the presence of numerous knob-like protuberances which repre- 
sent the intestinal haustra. The term scybala? is often used to 
denote the small and extremely hard, often dark, fecal masses 
which occur in constipation from any cause. It is probable that 
their formation is due to a prolonged sojourn of the feces in the 
recesses of the wall of the colon. 

Much importance was formerly' attached to the "lead pencil" 
stools as affording evidence of a stricture low down in the gut, 
and a similar significance was attached to the "sheep stools." It 
is now known, however, that these conditions may exist entirely 
independent one of another, so that in this particular the evidence 
of the stools must be disregarded. Spastic conditions of the gut 
may often be recognized by the small caliber of the stool, on which 
are to be seen the longitudinal markings of the muscular tamige of 
the colon. 

Color of Stools. — The color of the stools affords diagnostic 
information of very great importance, but is, unfortunately, some- 
what difficult at times to interpret. The normal color in adults 
is a dark brown, which is contributed by the oxidation products 
of the bile pigments. The variations in color, due to the food 
constituents, may considerably alter this tone, however. Thus, a 
predominantly meat diet gives a stool which is intensely brown, 
owing to the reduction of the hemoglobin. This shade becomes 
almost blackish after the use of a dish much in use among the 
German element of the population and known as "Blutwurst." 
A vegetable diet gives a more yellowish shade to the feces. The 
presence of undigested fats, as due pathologically to the failure 
of the bile to enter the gut, imparts a yellowish or even whitish 
tint. Other discolorations due to occasional or accidental admix- 
ture of special foods or drugs will be subsequently mentioned. 

Conner 1 has contributed recently to this important topic, and 
has suggested a provisional classification which is helpful. He 
finds it convenient to group the color changes as influenced by four 

1 Medical Xews. Auff. 30. 1902. 



164 EXAMINATION OF THE FECES. 

main series of features. These are: 1. Digestive secretions. 2. 
Food residue. 3. Discharges from the intestinal mucous mem- 
brane. 4. Accidental ingredients, e. g., drugs, etc. 

1. Digestive Secretions. — These secretions take a considerable 
part in the making up of the fecal mass. This is evident from the 
fact that in conditions of starvation or fasting, when the intestines 
contain no food whatever, the feces, which then consist only of 
the digestive secretions, mucus, desquamated epithelium and bac- 
teria, are of considerable quantity and of dark, pitch-like appear- 
ance. 1 

Of the various digestive juices the bile is the chief one taking 
any considerable part in furnishing color to the stools. Its role 
is an important one, however, and the history of the changes of 
this coloring matter from the time of its formation in the liver 
to its exit at the anus is instructive. 

The bile as secreted contains a single pigment — bilirubin. A 
part of this bilirubin is promptly oxidized, either in the bile pas- 
sages or soon after reaching the intestines, into biliverdin ^and 
several allied bodies. In meconium and in the stools of nursing 
infants, where putrefactive changes are slight or absent, biliverdin 
and bilirubin respectively appear as the normal ingredient. After 
the first few months of life, however, the bile pigments, under 
the influence of the putrefactive bacteria in the intestine and other 
enzyme actions, undergo a process of reduction to hydro-bili- 
rubin and intermediate products, and thenceforth never appear 
as constituents of normal stools. This hydro-bilirubin' then, a 
reduction product of bilirubin, constitutes the normal yellowish- 
brown pigment of the feces. It was described in 1871 by Vanlair 
and Masius, 2 who called it stercobilin. Soon afterward this was 
shown by Maly 3 to be identical with the urinary pigment urobilin. 
The change from bilirubin takes place usually in the small intes- 
tine, and both Frerichs and Nothnagel 4 have demonstrated by post- 
mortem examination that under normal conditions, neither bili- 
rubin nor biliverdin, as shown by their positive reaction to 
Gmelin's test, are found in the contents of the intestine below the 
cecum. A certain amount of hydro-bilirubin frequently, and per- 
haps always, undergoes still further reduction to a colorless body 
called by von Nencki leuco-urobilin. It is to the presence of this 

1 Fr. Miiller, Zeitschrift fur Biologie, XX, 1884, p. 327. 

2 Centralblatt fur med. Wissenschaften, IX, 1871, p. 369. 

3 Centralblatt ftir med. Wissenschaften, IX, 1871, p. 849. 

4 Die Erkrankungen des Darms, etc. (Spec. Path. u. Ther. Bd. XVII), 

Wien, 1898, p. 9. 



MACROSCOPIC EXAMINATION OF THE FECES. 165 

colorless cliromogenic body and its gradual oxidation back to hydro- 
bilirubin that Quincke 5 ascribes the gradual darkening in color 
which the surface of feces undergoes upon exposure to the air. 
This darkening in color upon exposure to the air is explained by 
Fleischer 6 as due simply to a process of drying and not to 
any chemical change, and he explains in the same way the very 
dark color of feces which have remained for a long time in the 
rectum. 

It follows from what has been said that variations in the color 
of the stool may permit of very important conclusions as to the 
condition of the liver and bile passages. If the stools are free 
from bile pigmentation they exhibit a pale color, the well-known 
"clay-colored" stools of biliary obstruction, the color of which is, 
however, also partly attributable to the presence of large amounts 
of undigested fats. An important diagnostic point is the recogni- 
tion of certain pseudo-acholic stools which present a similar shade 
in the absence both of icterus of the skin and of any disturbance 
in fat digestion. They are due to the further reduction of bili- 
rubin to colorless leuco-urobilin and become considerably darker 
on exposure to the air through reoxiclation of the pigment. If 
calomel be given to such individuals the stools regain their normal 
color, owing to the fact that the drug restrains the decomposition 
processes which free certain powerful reducing agents. 

In many diarrheas the stools present the golden yellow color of 
bilirubin, instead of the urobilin tint, owing to the fact that the 
stool is so rapidly carried through that there is not sufficient time 
for the processes of reduction to be completed. 

In the stools of infants the bile pigments occur normally in the 
unreduced form, as bilirubin, which gives them their golden yellow 
tint. Chemically, the presence of this bilirubin is easily deter- 
mined by Gmelin's reaction. Admixed with the bilirubin in the 
stools of infants is a certain amount of biliverdin. It is of impor- 
tance, however, to note that the green stools of infant diarrheas 
are frequently due to the action of a pigment producing bacillus 
(not the common Bacillus pyocyaneus.) 

An alkaline reaction in the intestinal content is essential to this 
series of changes. This fact explains the absence of the reduction 
products in certain acid diarrheas, e. g., in typhoid. 

Under certain circumstances, to be spoken of later, most or all 
of the hyclro-bilirubin may be reduced to leuco-urobilin and then 
the stools may simulate the clay-colored feces of jaundice. 

5 Munch, med. Woch.. 1896, p. 854. 

6 Lehrbuch der inneren Medicin. Wiesbaden. 1896. p. 1161, et seq. 



166 EXAMINATION OF THE FECES. 

But the bile derivatives are not the only coloring matters sup- 
plied by the digestive secretions. Ehrenthal 7 found that in starv- 
ing dogs with biliary fistula — L e., dogs in which neither food 
nor bile entered the intestine — dark-colored, pitch-like feces were 
passed whose color he ascribed to the pancreatic juice. Under 
normal conditions, however, this secretion probably has little influ- 
ence in determining the color of the stools. 

2. Food Residue. — With the usual mixed diet the food residue 
plays only a subordinate part in the make-up of the fecal color, but 
where the food has a pronounced and distinctive color this may 
modify considerably the appearance of the feces. So, for example, 
vegetables rich in chlorophyll, such as spinach or lettuce, may. 
give a greenish tint to the dejections and the abundant ingestion 
of carrots is said sometimes to impart their distinctive color. 8 

In general a vegetable diet produces much lighter colored stools 
than does a diet chiefly of meat. A meat diet alone is associated 
with very dark brown feces in which the color is due in part to 
the conversion of the blood-coloring matter of the meat into hema- 
tin (Fleischer). A diet of milk produces the familiar yellow or 
yellowish-white stools. 

In infants fed upon breast milk the feces have the orange yellow 
color of the yolk of egg ; the color being due to the presence of 
unchanged bilirubin, which, owing to the absence of putrefactive 
processes, is not changed in the intestine. With babies fed upon 
cow's milk, however, the stools have regularly a lighter, yellowish- 
white color. 

By the action of the alkaline contents of the intestine the red 
coloring matter of certain fruits, such as blackberries and huckle- 
berries, is so changed as to give to the stools a dark brown or 
slightly greenish hue. Red wine is said to produce a somewhat 
similar color. 

Quincke has called attention to the fact that the degree of trans- 
lucency of the ingredients of the feces has some effect upon the 
color ; that with the same quantity of coloring matter the stools 
appear the lighter the more they contain of such highly refractive 
bodies as fat droplets, crystals and gas bubbles. 

3. Discharges from the Intestinal Wall. — Among those which 
may modify the color of the dejections are mucus, pus, serum and 
blood. 

Mucus, although so common a constituent of pathological stools, 

7 Arch. f. d. ges. Physiologic XLVTII, 1891, p. 74. 

8 Schmidt u. Strasburger. Die Feces des Menschen, Berlin, 1901, p. 21. 



MACROSCOPIC EXAMINATION OF TEE FECES. 167 

does not usually give to them a distinctive color. When in large 
quantities, however, and when .thoroughly mixed with the feces 
these have a glistening, grayish or yellowish-gray appearance. 

Pus will, in rare instances, give a distinct yellowish or yellowish- 
gray tone to fluid stools. That this may occur two conditions are 
necessary ; first, that the pus be in large amount and, second, that 
it come from the lower part of the large intestine, since pus origi- 
nating higher in the intestine is so rapidly changed as to be unrec- 
ognizable in the stools by the naked eye. It is rarely seen, there- 
fore, in the stools except as the result of the rupture of some peri- 
rectal abscess. 

Serum, aside from giving to feces a watery consistence, will also 
impart its own straw color when the usual fecal pigment is lacking 
as, for example, in the rice-water stools of cholera, in which there 
is usually cessation of the biliary secretion. 

Blood can give to the feces a great variety of tints, depending 
upon its amount and upon the degree of change which it has under- 
gone. This latter corresponds usually to the length of time which 
the blood has remained in the intestine ; so that, in general, blood 
from the rectum or sigmoid flexure, which is promptly discharged, 
retains its normal color, whereas blood from the small intestine 
will have undergone such change, by the conversion of its hemo- 
globin into hematin, that it presents an appearance suggestive of 
coffee grounds or of tar. In such instances Teichmann's test for 
blood is useful in the determination. The presence of iron 
confuses the picture somewhat, as this remedy is often given after 
hemorrhage, and thus may constitute a source of error. Quincke 
has said, however, that the stools containing iron change their 
color to a blackish shade only after being exposed for some time 
to the air, while the stools of melena are passed in their tarry 
condition. 

The appearance of the blood indicates the location of the bleed- 
ing, however, only in a very general way, since with especially 
active peristalsis blood from high up in the small intestine may be 
discharged so promptly that little change will have occurred. If 
the blood be in small quantity and be intimately mixed with the 
feces it may give to the stools an orange tint suggestive of paprika 
(Xothnagel 9 ). Finally, it must be remembered that certain 
articles of diet, e. g., cocoa, huckleberries, etc., may produce in the 
stools an appearance which may easily be mistaken for disorgan- 
ized blood. 

9 Die Erkrankungen des Darms. etc. ; p. 84. 



168 



EXAMINATION OF THE FECES. 



4. Accidental Ingredients. — Drugs. Among the most interest- 
ing of the variations in the color of the stools are those produced 
by the use of certain drugs ; and concerning certain of these changes 
there is much popular misapprehension. 

Bismuth preparations produce a blackish or dark green color 
by the reduction of the ordinary salts (sub-nitrate, sub-carbonate, 
etc.) to bismuth hydroxide, and not the bismuth sulphide as so com- 
monly believed (Quincke). 

Calomel, contrary to the general impression, causes greenish 
stools (in adults at least) only infrequently and then, Quincke 
believes, not by the formation of sulphide of mercury but, appa- 
rently, by checking the putrefactive processes and by so preventing 

Fig. 66. 







: . £ k 



: ':}(W\ :: ' 4i>^4 •'V--^ ; ''- ' : V- : •^'•f,'^ 



Sulphide of bismuth crystals in the feces, (v. Jaksch.) 



the reduction of all the bilirubin ; so that instead of hydro-bilirubin 
the feces contain the greenish biliverdin. 

Iron usually does not affect the color of the stools until they 
have been exposed to the air for some time, when they become 
blackish gray, not from the presence of iron sulphide, but by the 
oxidation of some organic compounds of iron (Quincke.) 

Rhubarb, Senna and Santonin are said sometimes to give to the 
feces a yellow color. 

Methylene Blue causes no discoloration of the stools as passed, 
but within a few minutes these take on a bluish-green tint which 
gradually deepens. 

Kino colors the stools bright red, and Hematoxylin imparts a 
violet to violet red coloration. 



MACROSCOPIC EXAMINATION OF THE FECES. 169 

In this connection it is well to emphasize the fact that many 
stools, both those of infants and of adults, change their color very 
materially upon exposure to the air. Under such circumstances 
it is important to compare the color of the interior of the fecal 
mass with that of the surface. 

Bacteria. — In certain of the green diarrheas of children, Les- 
age 10 has found a bacillus, not Bacillus pyocyaneus, which develops 
in cultures a green pigment and which, he believes, stands in casual 
relation to the diarrheas. 

Salus 11 asserts also that Bacillus pyocyaneus can under certain 
circumstances give a greenish color to the stools. The common 
water Bacillus fluorescens and its congeners may induce a light 
fluorescence in the feces of infants. 

Clay-Colored Stools. — The association of grayish-white or "clay- 
colored" feces with obstructive jaundice has long been noticed 
and their lack of color, very naturally, ascribed to the absence of 
the bile coloring matters. Some years ago, however, Bunge 12 
announced that these acholic stools owed their clay color not to the 
absence of bile, but rather to the presence of an excessive quantity 
of fat, and he showed that by extracting this fat with ether such 
stools assumed a much darker color, which color he attributed to the 
presence of hematin and sulphide of iron from the food. 

The fact that the feces in obstructive jaundice contained enor- 
mous quantities of minute needle-shaped crystals had been noticed 
before. Gerhardt 13 believed these to be crystals of cholesterin. 
Their true nature as fat crystals had been proved, however, by 
Oesterlein, 14 Stadelmann, 15 and others. Franz Miiller 16 in some 
very careful investigations showed that, whereas in normal feces 
only from 7 to 10 per cent, of the ingested fat could be recovered, 
in obstructive jaundice the feces contained from 55 to 78 per cent, 
of the total quantity of fat eaten. That the gray color of such 
stools was due, however, to this fat and not to the lack of bile 
remained for Bunge to show. His observations were soon verified 
by Fleischer. 

Clay-colored feces, in cases of jaundice, in which neither bili- 
rubin nor hydro-bilirubiii could be found, would invariably, upon 

10 Archives de Physiologie, IV, Serie, Tome I, 1888, p. 212. 

11 Prag. med. Woch., 1894, No. 33. 

12 Lehrbuch d. physiol. u. pathol. Chemie, Leipzig, 1887, p. 192. 

13 Zeitschrift fiir klin. Med., Bd. VI, 1883. 

14 Mittheilungen aus d. med. Klinik in Wiirzburg. Bd. I. 1885, p. 1. 

15 Deutsch. Arch, fiir klin. Med., Bd. XL, 1887, p. 372. 
lfi Zeitschrift fiir klin. Med., XII, 1887, p. 101. 



170 EXAMINATION OF TEE FECES. 

treatment with ether, thus extracting the fat, show a much darker 
color. Fleischer was unable, however, to demonstrate iron sul- 
phide in such stools and believes the color to be due to hematin 
alone. But Ehrenthal has shown that the bile is not the only 
digestive secretion which gives color to the feces, and it seems prob- 
able, therefore, that this resulting color may depend upon several 
causes. 

Colorless Stools Without Jaundice. — It has also been noticed 
for a long time that typical, gray, clay-colored feces are occasion- 
ally to be seen where there is neither jaundice nor other evidence 
of biliary obstruction. Such stools have been seen by Eothnagel 17 
in leucemia, in cancer of the stomach and the intestines, in intes- 
tinal catarrh in children, and especially in cases of advanced 
phthisis. Von Jaksch 18 has noticed them in intestinal tuberculosis, 
chronic nephritis, chlorosis and scarlatina. Berggriin and Katz 19 
have called attention to their great frequency and their diagnostic 
value in chronic tuberculous peritonitis in children. 

Such light-colored stools seem, as regards their causation, to fall 
into two fairly distinct classes. 1. Those in which the lack of 
color is due to the great amount of fat present. 2. Those in which 
most of the bilirubin has been reduced beyond the stage of hydro- 
bilirubin to the colorless body leuco-urobilin (leuco-hydrobili- 
rubin). 

An excess of fat in the feces may result from several causes 
other than the lack of bile, (a) Ingestion of an unusually large 
quantity of fat even with normal digestion, (b) Disturbances of 
the fat absorption in the small intestine ; as, for example, with 
atrophy, amyloid degeneration, or tuberculosis of the mucous mem- 
brane, and especially by the occlusion of many lymph channels 
such as occurs with caseation of the mesenteric lymph nodes in 
tabes mesenterica and in chronic tuberculous peritonitis. Berg- 
griin and Katz have shown that the light-colored stools so fre- 
quently seen in chronic tuberculous peritonitis in children depend 
upon an excessive amount of fat, and they regard such stools as of 
considerable diagnostic significance, since the presence in them of 
hydro-bilirubin is proof that the fat is not due to the absence of 
bile, (c) Finally, it is possible that the absence of the pancreatic 
juice from the intestine may occasionally cause such fat stools. 
That it always, or even usually, does so, however, is certainly not 

17 Die Erkrankungen des Darms, etc., p. 18. 

18 Klin. Diagnostik inneren Medicin, II Anf., Wien, 1889, p. 213. 

19 Wien. klin. Woch., 1891, p. 858. 



MACROSCOPIC EXAMINATION OF THE FECES. 171 

the case. Much of the clinical evidence is entirely opposed to the 
view that disturbed pancreatic function is associated with an in- 
creased amount of fat in the feces (Nothnagel). 

Of the second class of clay-colored stools without jaundice — 
those due to the reduction of bile pigment to the colorless body 
leuco-urobilin — much less is known. It is certain that not all such 
stools contain an excess of fat. Quincke states that this reduction 
to leuco-urobilin may be so great that for weeks at a time, without 
obstruction to the bile, almost colorless feces may be discharged 
in which the extraction by alcohol furnishes an abundance of 
hydro-bilirubin. The conditions favoring this abnormal reduction 
of bile pigment to leuco-urobilin are by no means clearly under- 
stood. They seem to be connected usually, however, with in- 
creased putrefactive changes in the intestines. 

The separation of these two types of colorless stools is usually 
not difficult, since the second class can be identified by the lack 
of an increased quantity of fat and by the prompt darkening of 
color, upon treatment with acid alcohol, as the leuco-urobilin is 
oxidized to hydro-bilirubin. 

Green Stools. — These, except in those infrequent cases in which 
the color is due to definite chromogenic or fluorescent bacteria, or 
to the food, are always caused by the presence of biliverdin. This 
pigment may be said never to occur as a normal constituent of the 
feces except in meconium. In infants, however, where the putre- 
factive processes in the intestines are slight, and where bilirubin 
is found normally in the feces, biliverdin will appear upon slight 
provocation. The green color may be present when the stool is 
passed or may develop only after it has stood for some time. 

Biliverdin is found in the stools of children in diarrheas of 
many sorts. Such stools are usually alkaline in reaction, and both 
PfeifTer 20 and Biedert believe that the appearance of biliverdin 
is associated with increased alkaline reaction of the contents of the 
upper part of the small intestine. 

In adults green stools are of much less frequent occurrence, but 
are occasionally seen in certain diarrheas. Fleischer believes that 
they occur only where there is inflammation with increased peri- 
stalsis of both small and large intestine and never when one or the 
other alone is involved, since with normal peristalsis in either large 
or small intestine there would be time for the reduction of the 
biliverdin to hydro-bilirubin. 

Odor. — The odor of the stools in starvation is practically nil. 

20 Jahrbuch fur Kinderheilkunde. XXVIII, 1888, p. 164. 



172 .EXAMINATION OF THE FECES. 

It is the fermentation and putrefaction of the food which lends 
the stool a characteristic and often diagnostic odor. The odor of 
normal adult stool is chiefly derived from the products of proteid 
decomposition, indol, skatol, etc., and is, therefore, stronger in case 
of predominantly meat diet, in constipation, and in certain forms 
of putrefactive dyspepsias due chiefly to bacteria. The excessive 
decomposition of carbohydrates gives an odor of acetic or butyric 
acid. The latter fact affords an important sign in case of infant 
dyspepsias, inasmuch as the normal stool of infants has practically 
no odor. The stools in many forms of diarrheas, e. g., cholera, 
dysentery, are so rapidly passed and voided that there is no time 
for decomposition, hence no odor. In amebic dysentery the stools 
have a peculiar, glue-like odor. The stools of dysentery and' in- 
testinal carcinoma have often a very sickening, stinking odor. 

Macroscopic Elements. — The elements macroscopically recog- 
nizable in the feces are derived either from the food or from 
the intestinal apparatus itself. As regards the remains of the food, 
it has long been known that these are recognizable as such, and the 
older authors were accustomed to describe as characteristic of "lien- 
tery," a stool in which large amounts of undigested materials were 
present. Unfortunately this fairly accessible branch of coprology 
is not at present of great diagnostic moment. 

Food remains may occur in the feces because they are essentially 
indigestible. In this category belong masses of cellulose, bone, 
epidermis, the skin of many fruits, etc. Again, insufficient sub- 
division of the particles, or imperfect cooking, may be responsible 
for the passage of food boluses, notwithstanding a normal condi- 
tion of the digestive tract. Similarly, if a considerable excess of 
any particular article of diet be present in the food a certain 
amount of this may be rejected and reappear in the feces unaltered. 
Aside from these examples, however, the presence of masses of 
undigested articles may be regarded as indicative of disease. A 
special interest attaches to the occurrence of fish bones and of 
animal connective tissue, inasmuch as these are digested solely in 
the stomach and may be interpreted as evidence of gastric ineffi- 
ciency. In every other particular, how r ever, the gastric digestive 
functions are replaceable by those of the intestine, and even com- 
plete achylia gastrica does not otherwise affect the character of the 
stools. Starchy foods are the most easily digested element in the 
normal diet, and do not appear in the feces except when ensheated 
by a layer of cellulose, or in cases of increased peristalsis with 
diarrhea. Meats when properly prepared are also easily digestible, 



MACROSCOPIC EXAMINATION OF THE FECES. 173 

and their presence in the feces argues a serious fault in digestion. 
This may be due either to absence of the pancreatic secretion, as 
in cases of blockage of the duct or of atrophy of the gland, or to 
absence of the succus enter icus, which contains the recently dis- 
covered ferment k 'enterokinase," (Pavlow) as in cases of amy- 
loidosis and of tabes mesaraica. Xot only secretory disturbances, 
however, but rapid propulsion of the food through the gut, as in 
cases of diarrhea, may produce the same phenomenon of undigested 
muscle in the stool. Thus, its presence cannot be regarded as 
pathognomonic of any particular condition, but must be brought 
into relation with other phenomena. 

The presence of another proteid, casein, in the stools of infants 
is easily recognizable by the whitish, crumbly appearance, and is 
of considerable diagnostic value. Fats rarely appear in recogniza- 
ble amount in the feces. In cases of biliary obstruction, however, 
they are undigested, and may appear either finally divided through- 
out the feces, in which case they are recognizable by the whitish 
color, or, more rarely, as visible conglomerations of fats or fatty 
acids. The presence of certain undigested vegetable particles is 
not pathological. 

Elements derived from the body itself are pus, blood and mucus. 
The presence of mucus, and its character, afford very valuable evi- 
dence of intestinal conditions. The mucus of the feces is derived 
partly from the goblet cells of the intestine, the large intestine 
being incomparably more active in its production than the small, 
and is partly contained in the bile. It is chemically pure mucin. 
In its passage through the small intestine it becomes digested and 
the chyle passes into the colon practically free from it. Under 
ordinary conditions the feces macroscopically contain no mucus. 
Hard fecal masses, however, may, during their sojourn in the 
lower colon, obtain a more or less complete coating of mucus from 
this portion of the gait, and this offers the only exception to the 
assertion of Xothnagel that mucus in the feces is invariably an evi- 
dence of intestinal "catarrh." According to its form and distribu- 
tion in the feces very valuable inferences may be drawn as to the 
seat and nature of the pathological process. Mucus may appear as 
small, more or less transparent blobs or shreds, or as minute sago- 
like bodies, or as large semi-translucent jelly-like masses; or under 
certain well-defined conditions as dense, leathery, tape-like masses. 
If pure, it is clear, translucent and colorless. Frequently it 
becomes stained brown by imbibition of feces, or reddish yellow by 
bilirubin. If admixed with pus or epithelia, it becomes whitish 



174: EXAMINATION OF THE FECES. 

and opaque. If the feces are solid it never occurs in the interior 
of the mass, but always as an external coating, in which case it is 
undoubtedly derived from the large intestine. 

Mucus derived from a catarrh of the small gut is ordinarily 
completely digested and leaves no remnant in the feces, but, under 
certain conditions, it may be identified, and its origin determined. 
Thus, if the chyle be driven through with increased rapidity, it 
often escapes digestion. The feces are then semi-fluid from 
failure of absorption of its water, and intimately mingled with 
it are small particles of the mucus. These small particles are apt 
to be confused with remnants of food, especially of fruits. They 
are most easily recognized by allowing the stool to flow slowly down 
the surface of a blackened glass plate. Chemically, they are then 
easily identified either under the microscope or by the aid of the 
triacid reaction, with which they stain blue, while proteid constitu- 
ents stain red. This triacid reaction, which is best applied after 
rapid fixation of the material in 2.5 per cent, sublimate, fails, 
unfortunately, to differentiate vegetable material from mucus. 
The test is very simply applied. A small mass of the suspected 
material is allowed to dry in the slide, passed through the sublim- 
ate, and retained in Ehrlich's triacid until distinctly colored (1-5 
minutes), and then washed off. 

Certain other characters indicate the origin of this mucus from 
the higher portions of the intestine ; namely, its discoloration by 
bilirubin and the admixture with semi-digested epithelia or leuco- 
cytes. The diagnosis of duodenal or jejunal catarrh from the char- 
acter of the mucus in the stool is, nevertheless, almost foolhardy ; at 
most, one may say that the finer the subdivision of the mucus and 
the more intense the bilirubin discoloration, the higher is the seat of 
the process. The absence of mucus does not, of course, exclude the 
existence of a catarrh. Very characteristic are the almost 
leathery, tape-like masses of mucus expelled in muco-membranous 
colitis. They originate invariably in the large intestine. 

Not only the site, but the character of the process is, to a certain 
extent, revealed by the mucus. Pure mucus indicates a simple 
"catarrh ;" admixture of pus or epithelia indicates an inflamma- 
tion; large coherent masses are generally due to a secretory neu- 
rosis. 

Pus does not appear as a macroscopic constituent of the feces, 
except in cases of perforation of an abscess into the gut. The pus 
cells, which occur in the various ulcerative processes, are, with diffi- 
culty, recognizable, even microscopically, owing to their digestion 



MACROSCOPIC EXAMINATION OF THE FECES. 175 

and fragmentation. Blood in the stool is ordinarily recognizable 
by its color. If it originates high up, it is apt to become much 
darker through reduction processes during its progress downward. 
The blood from gastric hemorrhage is usually black and tarry. 
Hemorrhages from the colon, or even from the lower end of the 
ileum, as in typhoid, usually stain the stools a far more intense 
red. Blood derived from the small intestine is usually intimately 
mixed with the stool, while that from the lower colon or rectum 
forms an external layer. The microscopical examination is gener- 
ally of little assistance, inasmuch as the corpuscles become greatly 
altered. If fairly well preserved, their origin from the lower part 
of the gut may be inferred. The spectroscopic and chemical iden- 
tifications of blood are treated of in a later section. 

Other macroscopic elements are tumor masses, stones, parasites 
and foreign bodies. Tumor masses rarely appear in the feces ; 
they are derived either from carcinomata or are pedunculated fibro- 

Fig. 67. 




Gall-stones. (Simon.) 
a, cholesterin; 6, pigment-stones. 

adenomata which have broken loose. The former are irregular, 
crumbly, blood-stained; the latter are firmer and generally 
rounded. The microscopical examination of frozen sections is 
often of great assistance in differentiating them from food rem- 
nants. Stones are either biliary, pancreatic or fecal concrements. 
Biliary concrements vary in size from a pea to a pigeon's egg. 
Smaller stones are, as a rule, dissolved in the intestine. They are 
generally easily fragmented, and are either reddish brown bili- 
rubin calcium, or whitish and shining (cholesterin). The chemical 
determination of these constituents is quite simple, and will be 
subsequently described. 

If the stones are larger than a pea, their cystic origin is almost 
certain; if they are facetted, the existence of numbers of them 
may be inferred, and if they are only large, there is a cholecyst- 
enteric fistula. Frequent sources of error are the so-called "pseudo- 
gallstones" and inspissated masses of olive oil. Pseudo-gallstones 



176 EXAMINATION OF TEE FECES. 

are similar masses derived from the core of fruits, especially pears. 
They are much harder than gallstones, differ chemically, and pre- 
sent characteristic "stone cells" under the microscope. Pancreatic 
stones are rare. They are no larger than a pea, contain no bile 
pigment, and consist chiefly of calcium carbonate. Coproliths, or 
fecal concretions, are also rare, and are composed of undigested 
masses mixed with calcium and magnesium phosphate. The 
chemical examination of these stones is simple, and proceeds 
exactly as in case of bladder stones. 

Parasites will be described under a special section. 

Foreign bodies are not infrequent and are easy of recognition. 
Notable are the hair balls in young women, similar to gastric 
bezoares. 



CHAPTEK XV. 

MICROSCOPICAL EXAMINATION OF FECES. 

Method. — Microscopical examination of the stools demands a 
more or less homogeneous semi-fluid condition. Solid stools must, 
therefore, be rubbed up with a certain amount of water for this 
purpose. The semi-fluid stools may either be allowed to sediment, 
and the more solid portions withdrawn by a pipette, or they may 
be centrifuged. Save in very liquid stools, centrifuging is rarely 
necessary. The sediment usually settles in more or less distinct 
layers. At the bottom are the larger crystals, or larger masses of 
muscles, or heavier vegetable tissues, stone cells, bast fibers, etc. ; 
on the surface are fats and fatty acid crystals and lighter cellulose 
structures. The process of separation may be perfected by centrif- 
uging first with water acidulated with HC1, then with absolute 
alcohol, and finally with ether. This removes the alkaline salts, the 
ethereal oils and chlorophyll, and the fats successively, leaving only 
the undigested residue, and the acid salts. The microscopical exam- 
ination is greatly assisted by certain well-known microchemical re- 
actions, which demand the use of the following reagents. These are 
not essential, but are of much assistance in determining minute 
detailed structures: Acetic acid, 30 per cent; potassa, 10-15 per 
cent, solution, LugoFs solution, Lysol solution, 5 per cent., osmic 
acid, watery solutions of eosin and methylene blue. Any one of the 
proteid test reagents, e. g., Millon's. 

Meat Residue. — Muscle remnants, recognizable as such, are 
normally present in all stools after a mixed diet. Their amount 
depends on the amount of meat in the diet, the kind of meat, and 
its method of preparation. Tough meats, meats containing much 
connective tissue, and imperfectly cooked meats are apt to leave 
a proportionally greater residue. Muscle fragments appear in the 
feces in size varying from microscopic detritus to macroscopic 
pieces. When seen under the microscope, they appear either as 
irregular, polygonal fragments, or more or less rounded. They 
may be distinctly striated, or entirely homogeneous, in which case 
their nature must be ascertained by the microchemical reactions. 
The smaller, the more perfectly rounded, and the more homo- 
geneous they are, the more advanced is their digestion. The frag- 

12 (177) 



178 



EXAMINATION OF THE FECES. 



ments are discolored either by urobilin or bilirubin. Even if 
morphologically unrecognizable, they answer to the various proteid 
tests, e. g., the biuret, Millon's or the xanthoproteic. Acetic acid 
causes them to swell up, and brings out the striation; caustic 
potash dissolves them. 

The diagnostic evaluation of the presence of muscle remnants 
demands much experience. The only accurate tests are those 
offered by a quantitative estimate after the use of a test meal as 
suggested by Schmidt, and this is too complicated for 
routine purposes. The same author states that 100 grammes 
of browned scraped beef should normally leave no mac- 
roscopic residue. If, however, one is convinced that the 




Collective view of the feces, (v. Jaksch.) (Eye-piece, III; objective, 8 A, Reichert.) 
a, muscle-fibers; 6, connective tissue; c, epithelium ; d, white blood-corpuscles ; e, spiral 
cells ; /, pitted ducts ; g, cork cells; h, parenchyma with starch ; i, plant hair ; k, triple phos- 
phate crystals in a mass of various micro-organisms ; I, stone cell. 

muscle remnants are present in excessive amount, the con- 
clusion is inevitable that there is digestive disturbance in 
the small intestine. The nature of this disturbance, whether 
secretory, * motor, or absorptive, cannot be determined, and 
it is highly probable that all three factors are in most cases 
simultaneously concerned. Diarrheas, fevers, amyloidosis, tabes 
mesaraica, and pancreatic disease are possible causes. 

The presence of nuclei in microscopic remnants argues, theoret- 
ically, for pancreatic disease. In this connection may be men- 
tioned the use of Sahli's glutoid capsules to diagnose pancreatic 
disease. This test will be found described in Sahli's text-book of 
clinical laboratory methods. Capsules are prepared of gelatine 
hardened in formalin, which are indigestible except in pancreatic 



MICROSCOPICAL. EXAMIXATIOX OF THE FECES. 179 

juice. These are filled with iodoform glycerine. The discovery 
of iodine in the urine or saliva after the administration of one of 
these capsules is taken to indicate the functional activity of the 
pancreas. 

Connective Tissue. — Filaments of connective tissue occur in 
all feces after a mixed diet. They may either be microscopic, or 
form considerable masses, which, to the unaided eye, are indistin- 
guishable from conglomerates of fibrin, of vegetable fiber, or of 
elastic tissue. Microchemically, they swell up and become homo- 
geneous on the addition of acetic acid, whereas the same reagent 
brings out elastic tissue more sharply, and produces precipitates 
in mucus. Vegetable fibers may usually be distinguished by their 
structure, and with certainty, by their not reacting to the usual pro- 
teid reactions (xanthoproteic, etc.). There is no diagnostic 
significance to be attached to the occurrence of connective tissue 
fibers, unless they are present in large masses ; even in this event it 
is well to be sure that the meat of the food has not been of the 
"smoked" variety, and has been fairly well cooked, since even nor- 
mal digestions reject the unaltered connective tissue. Schmidt 
has asserted, as a quantitative test, that 100 grammes of cooked 
scraped beef should normally leave no connective tissue residue in 
the feces. If the tissue be found after such a meal, or be present in 
large amounts in case of an ordinary mixed diet, it is pathogno- 
monic of disturbance in the gastric functions, since only the stom- 
ach possesses the property of digesting this constituent. 

Elastic tissue regularly reappears in the feces, being extremely 
indigestible. It is easily recognized, but has no diagnostic signifi- 
cance. 

The presence of a bilirubin stain of connective tissue, and of 
undigested nuclei, has the same significance as noted in the case 
of muscle. 

Casein. — Of the other constituents of an animal diet, the vast 
majority leave no recognizable residue in the feces. Those tissues, 
which were noted in the section on the macroscopic residue as 
indigestible, reappear, of course, under more or less altered form 
in the microscopical examination. Fish scales, epidermis, feathers, 
etc., belong in this category, but most important are the epidermal 
remains. These latter appear generally as stratified, irregular, 
more or less refractile elements, and ordinarily possess no nuclei 
In the stools of infants, epidermis cells derived either from the 
mother's breast or from the child's fingers, might cause some 
confusion. 



180 EXAMINATION OF TEE FECES. 

Other forms of animal food, such as sweetbreads, brain, liver, 
leave no recognizable residue, except in case of pancreatic disease. 
They are so easily destroyed that even in case of considerably in- 
creased peristalsis, their morphological features are obliterated. 
Most important from a diagnostic standpoint are the remains of 
undigested casein, either in the feces of milk-fed infants or of 
adults on a milk diet. This appears as nocculi or clumps, the 
latter varying in size from microscopic masses to portions as 
large as lima beans. Except in cases of biliary obstruction these 
masses externally are always more or less deeply stained by biliary 
pigments or their derivatives, yellowish or brown, while the interior 
generally retains its white tint. They are homogeneous, amorphous 
masses, both macroscopically and microscopically, although even 

Fig. 69. 





m 'Tf Y 




11 Wmm> 

-a 


V 

r r : y ; \ f . . " 





C9 



Casein nocculi. a, casein ; b. fat. ( From Schmidt and Strasburger. ) 

low magnifications often reveal an admixture of fat and fat crys- 
tals. Microchemically they react to Millon's reagent, and are dis- 
solved by solutions of 5 per cent, hydrochloric acid. They are 
hardly to be confused with anything except certain minute masses 
of fatty acid crystals, the nature of which at once becomes clear 
on microscopical examination. 

The diagnostic value of casein stools is made much of by 
pediatrists. It must be taken, however, only as a symptom of func- 
tional disability to cope with the ingested casein, and not neces- 
sarily as a sign of organic disorder. Nevertheless,, it offers a val- 
uable dietary indication to alter either the quality or the quan- 
tity of the milk. 

The same indication holds true in case of adults who, for any 
reason, are on a milk diet, e. g., typhoid patients ; here the exam- 



PLATE VIII 



n 9 i. r 



o 




Fi 9 3 






\j% 



r»w A 



c 

• o 



Fig. 















b 



1 usele remnants in feces : a, large ; b, medium ; c, small fragments. (Leitz, obj . 7 .) 
Pig. 2 —Bile-stained albumin embedded in fecal mucus. (Leitz, Via-) 
Pig. 3.— Meconium : a. meconium corpuscles; b, fat; c, eholesterin crystals; d, epidermis. 

4.— Neutral fat: a, from the stool of an adult, bilirubin-stained ; b, from an infant ; 
ned with osmie acid. (Leitz, 7.) 
Pig. 5._Soap, in crystals and masses: a, circle-shaped forms from typhoid stools; 6, 
yellow calcium salts. (Leitz, obj. 7.) From Schmidt and Strasburger. 



MICROSCOPICAL EXAMINATION OF THE FECES. 181 

ination of the feces for casein is necessary to determine whether 
the diet is accepted as food or not. 

Vegetable Proteids. — Vegetable proteids, such as occur in cer- 
tain vegetables, fruits and particularly in nuts, are a highly 
digestible and nutritious element of the diet in themselves. Being 
inclosed within a cellulose envelope, however, they often pass 
through the intestinal canal unaltered, and are then discovered 
microscopically or microchemically. 

In most seeds, pea, bean, nuts of all kinds, the vegetable pro- 
teins are largely massed into crystalline form, making up the 
aleurone grains. These are very prominent in many seeds, and 
are even sufficiently characteristic to offer considerable aid in the 
diagnosis of the particular class of food ingested or undigested. 
As a rule, however, the aleurone grains are soluble in water, and 
are very readily dissolved out of the cell membranes, even though 
these latter are unbroken. In acute diarrheal conditions, partic- 
ularly of the motor variety, unaltered aleurone grains may be 
found in foods of the type mentioned. 

Observations regarding the solubility of these grains in patholog- 
ical fluids, such as the serous discharges of fermentative diarrheas, 
are wanting. Such might offer an attractive field for research. 

Fats.— Necessary to an appreciation of the fats and their deriv- 
atives, and of their diagnostic significance in the feces, is an under- 
standing of the chemistry of these compounds. The fatty compo- 
nents of the food are almost entirely in the form of neutral fats. 
These are technically triglycerides of the fatty acids. Glycerine 
is an alcohol containing three hydroxyl groups, having the formula 
C 3 II 5 (OH) 3 . When the fatty acids unite with the alcohol radical, 
they displace the hydroxyl groups, and a neutral fat is formed. 
The chief of these, as found in the food, are olein, palmitin and 
stearin, which occur as the chief fats of the animal body. Other 
fatty acids which combine to form fats are caproic, butyric, and 
others. The vegetable oils contain a far greater proportion of un- 
combined fatty acids than do the animal fats. 

The digestion of fats consists of a series of operations in which 
different parts of the alimentary tract severally take an important 
share. In the stomach the splitting of fats is begun through the 
agency both of micro-organisms and of a recently-discovered fer- 
ment. In the duodenum the fats are finely emulsified by the 
bile, and then split up by the steapsin of the pancreatic secretion 
into glycerine and fatty acids. The acids remain in part as such, 
in part unite with the salts of the alkalies present, sodium, potas- 



182 • EXAMINATION OF THE FECES. 

sium and calcium chiefly, to form soaps. These soaps and salts 
then pass into solution in the bile, and are so absorbed! Neutral 
fats cannot be absorbed, nor can soaps or fatty acids in the absence 
of bile. It will thus be seen that an analysis of the stools with 
reference to the diagnostic significance of their fat contents is no 
simple matter. 

Fat occurs in all feces, normal and pathological, and may be 
recognized in the form either of neutral fats, soaps, or fatty acids. 
Fatty stools, e. g., the "fat diarrheas' 7 of infants, are recognizable 
as such macroscopically, by their whitish color, often a peculiar 
sheen, and in liquid stools by the presence of a thin floating layer 
of fatty acid crystals. 

Neutral fats appear either as droplets or as masses with irregu- 
larly-rounded contours. This difference depends in a difference in 

Fig. 70. 





^m " 



Crystals of the fatty acids, a, mingled with mucus ; 6, around fat droplets in an infant's 
stool to which glycerin has been added. (From Schmidt and Strasburger. ) 

melting points, the former having the lower point. The droplets are 
colorless, the irregular masses more or less deeply bile-stained. 
Microchemically, the neutral fats are insoluble in water, barely so 
in cold alcohol, soluble in ether, chloroform and hot alcohol. Osmic 
acid stains them a dense black ; this, however, is strictly true only 
of the olein fats, the other forms must first be treated with alcohol, 
and then stain a rusty red to black. 

The fatty acids, such as butyric acid, are in part volatile, and 
rapidly evaporate from the feces. The lower forms occur both as 
amorphous masses, similar to those composed of neutral fats, and 
as crystals. The crystals are generally sheaves of very delicate, 
point-tipped, needles. Microchemically, they may be identified 
by their solubility in cold alcohol. The crystals are always free 
from biliary coloring matter. With osmic acid they stain coarsely 
and irregularly black. 



MICROSCOPICAL EXAMINATION OF THE FECES. 183 

The soaps occur microscopically either as amorphous masses, 
or crystals. The amorphous masses may be colorless, or stained 
by biliary pigments. Their contour is said to present more angu- 
larities than do those of fats or fatty acids. The crystals are gen- 
erally in the form of colorless needles, often arranged in sheaves, 



Fig. 71. 



Jill 



a~ 



■% P 
) I 



// y,^-~>~ 
o, fatty acid amorphous masses ; b, soap crystals. (From Schmidt and Strasburger.) 

and are shorter, broader and blunter than those of the fatty acids. 
Another form described resembles the egg of Taenia. 

Microchemically, one must distinguish between the calcium 
salts which constitute the greatest portion of the soaps, and the salts 
of the alkaline metals. The former are insoluble in hot water, 
alcohol or ether, and do not stain with osmic acid or Sudan red. 

Fig. 72. 

.■■■ x -.h w/, 





I 

b 

«, masses of soap ; 6, Nothnagel's " islands of hyaline mucus." 
(From Schmidt and Strasburger.) 

On heating they do not change to droplets, as do the crystals of 
fatty acids and the neutral fats. If they are warmed in the pres- 
ence of acids, fat droplets are formed, simultaneously with the 
corresponding salt of the acid introduced. The latter differ in that 
they are soluble in hot water and alcohol. 



184 EXAMINATION OF THE FECES. 

The pathological significance of fats in the feces can be under- 
stood only with reference to normal conditions. Thus in infants, 
owing to an incomplete development of the fat-splitting function, 
there is always a considerable amount of "fat in the stools, which 
decreases as the child grows older; fat droplets, crystals and 
amorphous masses are all present. Biedert has described a "fatty 
diarrhea," in which the fats are a preponderant element in the 
stools, and this is certainly ' pathological even in infants. In 
adults, it is rare to find neutral fat droplets, except after the inges- 
tion of large amounts of oils of low melting point, as olive oil or 
castor oil. Normally, fats occur in small amounts as amorphous 
masses of soaps, more rarely as crystals. The presence of large 
amounts of neutral fats is always pathological, and is betrayed 
even macroscopically by the glistening, soft character of the stool, 
with a whitish tinge. 

Fig. 73. 




Feces of jaundice, (v. Jaksch.) 

Fatty acids have been found by Herter in large amounts in the 
feces, as the splitting of fats into glycerine and the fatty acids may 
take place energetically in the lower part of the small intestine 
under the influence of organisms of the colon bacillus group. 

The exact nature of the disturbance must be gathered from other 
signs, inasmuch as increased peristalsis, amyloidosis, biliary ob- 
struction and pancreatic disease all interfere with the absorption of 
fats. The distinction, however, is generally easy to make between 
these conditions. 

In pancreatic disease there is not necessarily so much a quantita- 
tive increase in fats as a qualitative change, inasmuch as the exclu- 
sion of the pancreatic fat-splitting enzyme (steapsin) from the gut 
leads to the presence of a far larger proportion of neutral fat. In 
biliary obstruction, on the other hand, although complete splitting 
takes place, there is a diminution of the absorptive function, inas- 



MICROSCOPICAL EXAMINATION OF THE FECES. 185 

much as the bile acts as the vehicle or solvent of soaps and fatty 
acids, hence a preponderance of the latter in the stool. 

Crystals. — A variety of crystalline salts occur in the feces, 
especially the phosphates, and magnesium and calcium salts. They 
have no diagnostic significance, and present the same morphological 
and microchemical reactions as already described for the urine. 

Cholesterin occurs in characteristic form, and is frequently 
found in the stools of infants. Charcot-Leyden crystals seem to 
occur with especial frequence in cases of helminthiasis and of 
mucus colitis, although occasionally in other conditions also. They 
are found in greatest number in the mucus itself. The crystals 
are apparently identical with those found in the sputum ; colorless 
octahedra, with sharp margins, and generally broken angles. Their 

Fig. 74., 




Cholesterin crystals. (Simon.) 

genetic relationship with the above named pathological conditions 
is not clear. 

Hemin crystals probably are not to be found, but those of 
hematoidin occur occasionally either as needles, rhombs, or amor- 
phous masses of reddish-brown color. They seem to be especially 
associated with hemorrhages into the bowel or stomach, either from 
ulceration or congestive catarrhs. 

Similar in appearance, but of a lighter color, are the bilirubin 
crystals, which occur not infrequently in the diarrheal stools of 
adults. The latter are easily distinguished by their microchemical 
reactions, as elsewhere described. 

Crystals from vegetable foods are very numerous and charac- 
teristic. These are for the most part made up of calcium oxalate. 
Calcium carbonate crystals are also found in many vegetables. 



186 



EXAMINATION OF THE FECES. 



For microscopical purposes, however, only the calcium oxalate 
crystals need be considered. 

In general three prevailing types of these crystals are found, 
Needle shaped (r aphides), rosette forms, and rhomboids. Fre- 
quently these three may be associated in the same plant, but at 
times only one form may be present; rosettes, for instance, in 
rhubarb. 

In cases of markedly-increased acidity of the gastric juice 
(HC1), the calcium oxalate crystals may be dissolved, but other- 
wise they form a constant feature in the stools of a mixed diet, 
including green vegetables. A certain amount of the calcium oxal- 
ate is absorbed under most conditions. Occasionally, as seen in the 
chapter on urine, oxaluria is present, as a result of either increased 
ingestion of vegetable food containing large amounts of calcium 

Fig. 75. 




Hematoidin crystals from the feces, (v. Jaksch.) 



oxalate ; increased gastric acidity, rendering more soluble that 
which has been ingested ; oxidative metabolic defects, as yet imper- 
fectly understood (see urine oxaluria), by which complete oxida- 
tion of the oxalic acid does not take place. 

From a medico-legal point of view, a large chapter on plant 
crystals might be written, as practically all of the narcotic poisons, 
aconite, belladonna, digitalis, hyoscyamus, etc., when taken in 
their crude state leave residues either in the gastric contents or 
feces, which are identifiable largely from the plant crystals. 

Mucus. — The characteristics of mucus have been more or less 
fully described in the macroscopic section. Minute particles of 
mucus, such as are usually identified with catarrh of the upper 
bowel, may be most easily detected if the stools be mixed with 
water and allowed to trickle down the surface of a blackened plate, 
of glass. Microscopically, it appears as more or less homogeneous, 



MICROSCOPICAL EXAMINATION OF THE FECES. 187 

transparent masses, with faintly marked contours. It may occur 
as pure mucus, or mingled with leucocytes, epithelia, blood or food 
detritus. There may be slight discoloration by biliary pigments. 

The most characteristic microchemical reaction is that with 
acetic acid, which precipitates the mucus, producing at the same 
time irregular linear markings ; the same reagent "clears" the cells, 
and brings out their nuclei sharply. 

The diagnostic features of mucus are thus summarized by 
Schmidt and Strasburger: 

1. If the mucus be densely impregnated with bacteria, detritus 
and food remnants, this speaks for its origin high up in the 
intestine. 

Fig. 77. 



-A Ite 



n 



Fig. 76. \,V 



/ 



MSK«\. : ;,11W 



? l^vo? v ^vi>; mm 



I™ 



t^;^\ ill 






m& 




Mucus shreds. Mucus shreds after the addition 

(From Schmidt and Strasburger. ) of acetic acid. 

2. Bilirubin discoloration affords no certain evidence of, 
catarrh of the small intestine, but the presence of bilirubin gran- 
ules and crystals in a cellular arrangement may be interpreted in 
this sense. 

3. The presence of semi-digested cells, or of their nuclei, indi- 
cates a high origin. 

4. The presence of hyaline cells argues strongly for colon 
catarrh. Mucus unmingled with epithelia or pus cells indicates a 
far lower degree of inflammation than the opposite condition. 

Epithelium. — Epithelia form a constant constituent of all feces, 
owing to the continual attrition of the intestinal contents, and 



188 EXAMINATION OF THE FECES. 

perhaps to a spontaneous process of desquamation. Normally, 
however, they are so mingled with the feces, and generally so 
altered by digestion, that special attention must be directed to 
them in order to identify them. In catarrhal or dysenteric pro- 
cesses, however, they constitute a very prominent and important 
element. This is in striking contrast with the leucocytes which 
play but a small part in coprologic diagnosis. The conditions are 
thus the reverse of those which maintain in the sputum. Epithelia 
are of various types, according to the area of the tract from which 
they originate; those from the anus belong to the stratified 
squamous type, while those from the intestine are cylindrical. It 
is only rarely, however, that epithelium is passed out in a condition 
resembling at all closely that which it normally shows. Not only is 

Fig. 78. 





wam^m 



The so-called " Verschollte Zellen.". a, unaltered ; al, after the addition of acetic acid 
and heat ; 6, in the mucus from the colon. (From Schmidt and Strasburger.) 

it subject to the action of the various digestive juices in its passage 
through the gut, but the original intestinal epithelium may be in a 
degenerative condition. Thus it is important to recognize fully 
degenerated cells, which are often swollen to three or four times 
their ordinary size; semi-digested cells, with ragged contours, 
clouded protoplasm, and, at times, only the remains of a nucleus, 
and a peculiar type known to the German describers as " Verschollte 
Zellen," with an amyloid or starchy appearance. The last named 
form is very frequently seen, especially in connection with mucus. 
The cells are small, homogeneous, possess no nucleus, and show 
increased refractile power as seen through the microscope, like 
amyloid. They were long considered to represent this type of 
degeneration, until it was shown that the appearance is due to an 
imbibition with soaps. This imbibition in all probability repre- 



MICROSCOPICAL EXAMINATION OF THE FECES. 189 

sents not a vital cellular process, but a postmortem change of the 
cell, and is seen also in leucocytes. This form of cell is considered 
to indicate its origin from the large intestine. 

Epithelial cells occur in all inflammatory conditions of the intes- 
tine, and are generally imbedded in the mucus. If large masses 
of mucus are passed without a corresponding dejection of epithelia, 
the condition is almost certainly neurotic, "enteritis membranacea," 
and not inflammatory. 

Large masses of coherent cells, fairly well preserved, occur in 
toxic enteritides, with rapid passage of the intestinal contents, and 
in cases of strangulated intussusceptions. In general, the further 
digested the epithelia, the more probable is their origin from the 
small intestine. This probability becomes almost a certainty when 
these cells are imbedded in small clumps of mucus. 

Leucocytes. — The same alterations which disguise the epithelial 
cells are found in the leucocytes in the feces. Normally, 

Fig. 79. 




Degenerated intestinal epithelium, (v. Jaksch.) 

they may be found in small numbers in every stool. In catarrhal 
processes, whether acute or chronic, they are but slightly 
increased- and do not constitute nearly as prominent a feature of 
these conditions as do the epithelial cells. Their presence in 
greater numbers indicates an ulcerative affection. 

Pus in very considerable amount in the stool points to the rup- 
ture of an extra-intestinal abscess into the gut, and the better pre- 
served the leucocytes, the lower down may this be located. 

Eosinophiles occur in the feces in a few conditions, notably hel- 
minthiasis and muco-membranous colitis. They are recognized 
by their affinity for eosin, any one of the ordinary blood stains being 
available for the test. The rationale of their presence is not under- 
stood. Possibly the eosinophilia is related to that which occurs in 



190 EXAMINATION OF THE FECES. 

the blood in many cases of helminthiasis, while the eosinophiles 
in the stools of colitis membranacea may be compared to those 
found in the sputum in asthma. 

Erythrocytes. — Red blood cells, unless derived from the lower 
colon, are generally distorted beyond recognition in the feces; 
occasionally, "shadow corpuscles," which preserve the form, but 
not the color, may be found. If there is, however, a simultaneous 
diarrhea, the cells may be fairly well preserved. 

The detection of blood traces forms a very important chapter 
of the chemical examination of the feces, and will be there 
described. 

Diagnostically, fecal masses presenting external streaks of blood 
point towards bleeding hemorrhoids. Microscopic traces of blood 
in typhoid often precede larger hemorrhages. 

Fig. 80. 

Fibrin coagula. (From Schmidt and Strasburger.) 

Tumors. — Masses of intestinal tissue but rarely slough off, as in 
cases of intussusception. Occasionally particles of hemorrhoids 
come away. Carcinoma and adenoma occasionally part with 
sloughs, which may be examined either by means of scrapings or 
by microscopic sections. Polypi are sometimes passed complete. 

Nothnagel's Bodies. — Nothnagel, in 1884, described a form 
of mucus in the stool, which he considered characteristic of ileitis. 
It occurs in minute granules, bordering on the limits of the macro- 
scopic in size, the largest being of the size of the head of a pin. 
They vary in number, and in some cases are so numerous that the 
entire fecal mass, which then becomes almost fluid, simply swarms 
with them. They are yellow to brown in color. Their consistency 
is soft, and when crushed under a cover-glass they spread out in 
a homogeneous mass. They never contain epithelia or round cells. 



MICROSCOPICAL EXAMINATION OF THE FECES. 191 

Through work of Schorlemmer and of Schmidt, it is now quite 
clear that these bodies are not composed of mucus, but of albumin. 
The fact, however, that the bodies are generally imbedded in small 
shreds of mucus, and that they are colored with bilirubin, lends 
them the same diagnostic significance as was originally attributed 
to them by ]STothnagel, namely of an ileitis. Bilirubin, as has been 
said, occurs normally only in the ileum and never in the colon, 
and can only be found in the feces in case the peristalsis of ileum 
and colon is abnormally active. 

Meconium. — During the first two days of infant life a mate- 
rial is passed out of the rectum which differs both in origin, compo- 
sition and physical characteristics from the ordinary stool of the 
infant. This so-called meconium is of an olive color, soft, and is 
passed four to six times daily. It is composed of intestinal secre- 
tions and epithelial cells, of mucus, of bile,- of hairs, and of fat 
globules. Microscopically, there are epithelia in various stages of 
degeneration, cholesterin crystals, fats and the so-called meconium 
corpuscles. The latter are homogeneous, rounded globules, of a 
yellowish color. Their origin is uncertain, but they are in all 
probability albuminous in nature. 

VEGETABLE DETRITUS. 

The microscopical examination of the vegetable detritus in the 
feces is beset with many difficulties. This is not due so much to 
the changes induced by the various digestive processes, but more 
particularly to the great similarity that exists in the various plant 
cells that are so constantly used as food. 

In the present stage of its development, it is unquestionably true 
that very little information of a directly applicable character has 
been gained from the study of the vegetable remains in the feces. 
This has been due very largely to the fact that when compared 
with the wealth of detail obtained by other methods, the feces 
have very rarely been examined by the student of plant histology, 
and when so studied the rarer combination of gastro-enterologist 
and histologist has been lacking. 

The microscopical investigation of many of the common food 
products has been carried on by experts for years, but the point of 
view has almost always been that of the hygienist, who in his 
studies has been keenly alert to detect adulterations in foods. 
From this standpoint the study has been pursued with infinite 



192 EXAMINATION OF TEE FECES. 

detail. Such works as Vogl, 1 Wiesner, 2 Meyer, 3 Hanausek 4 and 
Greenish, 5 represent the best of the kind in any literature, and all 
testify to the intrinsic interest that studies of this kind possess, 
particularly from the standpoint of the sanitary expert on foods. 
Such works represent even a wider field, for their pages are filled 
with information directly applicable to the needs of the micro- 
scopist who would study the feces. It would seem that van Ledden 
Hulsebosch (1899) had been almost the only investigator to fully 
follow out these methods. 

These authorities have been here quoted in this manner, since 
the methods pursued in these volumes are the methods which must 
be followed by the student of the feces if definite conceptions 
regarding the action of the gastro-enteric tract upon the food' are 
to be gained. It will not take many years before a mass of practi- 
cal data can be accumulated if studies of this type are prosecuted. 

It is well known that the cells of plants differ very widely from 
those of animals in the possession of a distinct cell wall. This cell 
wall is composed largely of cellulose, or a modification of the same, 
or of a mixture of cellulose and modifications, variously termed 
cutin, suberin, lignin, etc. Cutinized cell walls are characteristic 
of the peripheral walls of plant organs of all kinds, leaves, stems, 
etc. Suberized cell walls are present in corky tissues; whereas 
lignified cell walls are present in stone cells, in various ducts and 
tracheids, and in wood fibers and in bast fibers. 

The substances causing these modifications are very imper- 
fectly understood at the present time, and, while their microchemi- 
cal characters in an unaltered condition are well known, very little 
is understood concerning these same microchemical characters after 
digestion. 

All of these modifications render cellulose much more unaltera- 
ble than when in its original condition, and in certain vegetables 
and fruits many cells with walls of these characters are encoun- 
tered. 

Ordinary cellulose is not as indigestible as has been taught, and 
it is by no means the exception to find the cellulose walls in many 

1 A. E. Vogl, Die wicbtigsten vegetabilischen Nahrungs und Genussmittel mit 
besonderer Beriicksichtigung der mikroskopischen Untersuchung auf ihre Ecb.tb.eit, 
ihre Verunreinigungen und Verfalscbungen. Vienna, 1889. 

2 J. Wiesner, Die Rohstoffe des Pflanzenreicbes, 2d edition, 1900. 

3 A. Meyer, Die Grundlagen und die Methoden fiir die mikroskopiscbe Unter- 
sucbung von Pflanzenpulvern, 1901. 

4 Lehrbuch der tecbniscben Mikroskopie 1901 

5 Greenish, Foods and Drugs 1903. 



MICROSCOPICAL EXAMINATION OF THE FECES. 193 

vegetables broken down by the digestive processes, especially when 
the masses of cellulose are not too bulky. This fact was maintained 
as early as 1870 by Weiske (Ztsch. f. Biologie), but has frequently 
been overlooked. The microchemical tests are also somewhat 
altered in many instances ; instead of the pure light blue caused by 
the addition of iodine and sulphuric acid to cellulose, an aborted 
reaction takes place. Often the cellulose residue is much more sol- ■ 
uble in copper oxyammonia solution than when acted on before the 
digestive processes have been active. Quantitative tests have not 
yet been found reliable to indicate any particular grade of digestive 
function. 

The action of weak alkalies (ISTaOH) on cellulose is to convert 
it partly into meta-arabic acid. This is partly soluble in water, 
and is possibly a part of the reaction that occurs in cellulose 
digestion microchemically. 

Just what processes take place in the intestines whereby simple 
cellulose is digested are not as yet thoroughly understood. Tap- 
peiner, Prausnitz and a score of others have endeavored to deter- 
mine the causes. It has been known for years that under the 
actuation of certain enzymes in germinating seeds the cellulose 
membranes swell, become converted into a soluble carbohydrate, 
and as such contribute to the nutrition of the young plant. The 
breaking down of cellulose, and even lignified cellulose, as found in 
wood (railroad ties, etc.), by moulds from the activities of cytases 
is a common every-day phenomenon, and it is further observed 
that certain lower organisms, yeasts and bacteria are capable of 
reducing cellulose to a soluble modification. 

The production of cytases in the intestinal canal has not been 
observed, but some degree of hydrolysis of the cellulose does occur. 
Whether this is due to the enzymes of normal intestinal bacteria, to 
alkalies, or to other vital ferment action is not yet certain. 

In normal digestion, however, it is found that the parenchymatic 
cells of those tissues which are young, and whose cell walls are very 
delicate, are found in the feces either to have been completely 
broken down, or sufficiently digested to permit ready breaking down 
of the cellular masses and the digestion of the cell contents. 

In mild, constipated states it has been observed that the cellulose 
walls have shown a greater degree of splitting, and it has been 
inferred that the prolonged stay in the large intestine has per- 
mitted more extended hydrolysis, presumably from bacterial action, 
and hence more cellulose modification. On the other hand, in 
diarrheal conditions, notably in irritative conditions of the small 

13 



194 EXAMINATION OF THE FECES. 

intestine in contradistinction to colitis, the grade of cellulose disin- 
tegration is distinctly less advanced, and the food plant cells, as 
found in the feces, show little alteration on comparison with the 
source in their fresh condition. 

Moeller 1 first pointed out that, whereas only thin cellulose walls 
were broken down in the digestive process, the pectin-like substances 
which constitute the middle lamellae of plant cells was almost invar- 
iably attacked, much as if they had been acted on by the well- 
known histological maceration agents, such as Schultze's. This 
permits the falling apart of the cells in any mass of tissue, and 
thereby aids the further digestion of the individual cells. 

This characteristic reaction offers another slight help in the 
interpretation of digestion. Thus the masses of cells are greater 
in those passages that have been hurried through the intestinal 
canal — a fact already known macroscopically. 

The microchemistry of cellulose offers little. In diarrheal states, 
the iodine (Iodine (1), K. I. (2) Aq. 200) sulphuric acid test 
(Cone, H 2 S0 4 ) may show little alteration of the cellulose. This 
test may not reveal any cellulose in the constipated stool. Chlor- 
iodide of zinc imparts a distinct violet tone to simple cellulose 
walls, and reveals similar facts. Szydlowski 2 thought by micro- 
chemical tests to simplify the question markedly, but beyond the 
few facts already pointed out, it cannot be said that his results 
have been verified. The test of solubility of the cellulose in the 
copper oxyammonia reagent is not readily applicable in this line 
of research. 

As for the results obtained from the study of cell contents, only 
the observations concerning chlorophyll, starch, aleurone grains, 
and crystals, seem of value. 

As to chlorophyll, it is frequently entirely destroyed in the intes- 
tine. When such vegetables as spinach, beet tops, etc., are eaten, 
and in comparatively large quantities, abundant evidences of un- 
altered chlorophyll grains are found in the feces. Moeller (1. c.) 
says that he has never demonstrated the presence of assimilation 
starch in the chlorophyll grains in these cases, although the fresh 
vegetable contains it in abundance. The significance of this test 
as an index of digestion has never been worked out. The pres- 
ence of such grains in the chlorophyll would argue a loss or reduc- 
tion in the amount of pancreatic diastatic ferment. 

Starch is the most characteristic formed element in most food 

^tschft. f. Biologie 17, 1897, p. 306. 

2 Beitrage z. Mikroskopie der Feces. Breslau Dissertation. 1879. 



MICROSCOPICAL EXAMINATION OF THE FECES. 195 

products. It is almost always digested in the normal process, even 
when it may be taken in comparatively large masses, such as rice 
grains or sliced potatoes. In normal digestion most cereal 
starches also show digestion. They are swollen if present at all, 
and do not show the typical blue reaction to weak iodine-potassium 
iodide solutions. In mild diarrheal conditions and in conditions 
associated with diminution of the pancreatic ferments, unchanged 
or only slightly modified starch is present. 

Starch in the well-known form of microscopic granules, 
with concentric or eccentric markings, is rarely seen in the 
normal stool, except when large amounts of raw or partially-cooked 
starch have been included in the food. On the other hand, starch 
masses enclosed in cellulose membranes are not infrequent. The 
partially-digested, dextrinized granules of starch, such as occur in 
normal stools, are, for the most part, no longer recognizable 
microscopically by their structure, and must be identified by their 
chemical reactions. The most characteristic of these is the blue 
coloration with iodine, generally employed in the form of Gram's 
or Lugol's solution. The semi-digested particles, "erythrodex- 
trins," stain a mahogany brown to reddish, while the final stages 
do not become discolored by iodine. In performing the test, it is 
necessary to bring about an intimate admixture of the chemical 
and the feces. 

Diagnostic ally, the presence in the stools of unaltered starch 
grains, except as enclosed in plant cells (cellulose), is a rarity 
under normal conditions. If isolated unaltered starch granules 
occur in any amount, one may argue a disturbance of digestion. 
The disturbance is localized in the small intestine, and is always 
severe in character. In searching for starch, care should be taken 
not to fragment the undigested vegetable particles which occur in 
most stools, thus, perhaps, setting free starch granules 'which were 
originally enclosed in a cellulose membrane. 

In the more commonly used cereals and starchy foods, the starcK 
grains are of characteristic shapes, so much so that in the unaltered 
condition their source may be recognized after the passage of the 
intestinal canal. 

The accompanying table of classification, adapted from Vogl, 
and from Wiesner 1 may serve to identify some of these more im- 
portant starches. 

^likroskopische Technologie. 



196 



EXAMINATION OF THE FECES. 
Fig. 81. 







S»8h 




The elements of wheat flour. Ep, epidermis; M and P, middle layer; Q, cells lying 
outside of hypodermis; S, seed coat; Al, aleurone cells; t, hairs; Em, cotyledon tissue; Am, 
starch. (Vogl.) 



MICROSCOPICAL EXAMINATION OF THE FECES. 197 

A. Granules simple, bounded by rounded surfaces. 

I. Hilum central, layers concentric. 

a. Mostly rounded or from the side, lens-shaped. 

1. Large granules, 0.0396-0.0528 mm. Eye starch. 

2. Large granules, 0.0352-0.0396 mm. Wheat starch. 

3. Large granules, 0.0264 mm. Barley starch. 

b. Egg-shaped, oval, kidney-shaped. Hilum often long and 

ragged. 
1. Large granules, 0.032-0.097 mm. Leguminous 
starches. 

II. Hilum eccentric, layers plainly eccentric or meniscus 

shaped. 

a. Granules not at all or only slightly flattened. 

1. Hilum mostly at the smaller end, 0.06-0.010 mm. 

Potato starch. 

2. Hilum mostly at the broader end, or toward the 

middle in simple granules, 0.022-0.0600 mm. 
Maranta starch. 

b. Granules more or less strongly flattened. 

1. Many drawn out to a short point at one end. 

a. At the most 0.060 mm. long. Curcuma starch. 

b. As much as 0.132 mm. long. Canna starch. 

2. Many lengthened to bean-shaped, disk-shaped or flat- 

tened; hilum near the broader end, 0.044-0.075 
mm. Banana starch. 

3. Many strongly kidney-shaped; hilum near the edge, 

0.048-0.056 Sisyrinchium starch. 

4. Egg-shaped; at one end reduced to a wedge, at the 

other enlarged; hilum at the smaller end, 0.05-0.07 
mm. Yam starch. 

B. Granules simple or compound, single granules or parts of 

granules, either bounded entirely by plane surfaces, many 
angled, or by partly-rounded surfaces. 

I. Granules entirely angular. 

1. With a prominent hilum. At most 0.0066 mm. Bice 

starch. 

2. Without a hilum. The largest 0.0088 mm. Millet 

starch. 

II. Among the many angled, also rounded forms. 

a. Few partly-rounded forms present, angular form pre- 
• dominatins.'. 



198 



EXAMINATION OF THE FECES. 



Fig. 82. 



schi 




Rye flour. Ep, epidermis ; P, middle layer ; Q, cells outside of hypoderm ; S, seed coat; 
Al, aleurone cells ; t, hairs; Am, starch ; Schl, fragments of bladder-like cells near Q,. (Vogl.) 



MICROSCOPICAL EXAMINATION OF THE FECES. 199 

1. Without liilnm or depression, very small 0.0014 mm. 

Oat starch. 

2. With hiluin or depression, 0.0132-0.0220 mm. 

a. Hiluin or its depression considerably rounded; here 

and there the granules united into differently- 
formed groups. Buckwheat starch. 

b. Hilum mostly radiatory or star-shaped; all the 

granules free. Com starch. 
b. More or less numerous kettledrum and sugarloaf-like 
forms. 

1. Very numerous eccentric layers; the largest granules 

0.022-0.0352 mm. Batata starch. 

2. Without layers or rings, 0.008-0.032 mm. 

a. In the kettledrum-shaped granules the hylar depres- 
sion mostly widened on the flattened side, 0.008- 
0.022 mm. Cassava starch, 
o. Depression wanting or not enlarged. 

aa. Hilum small, eccentric, 0.008-0.016 mm. 
Pachyrhizus starch. 
bb. Hilum small, central or wanting. 

aaa. Many irregular forms, 0.008-0.0176 mm. 

Sechium starch. 
bbb. But few angular forms ; some with radia- 
tory hilal fissure, 0.008-0.0176 mm. 
Castanospermum starch. 
C. Granules simple and compound, predominant forms egg- 
shaped and oval, with eccentric hilum and numerous 
layers, the compound granules made up of a large gran- 
ule and one or more relatively small kettledrum-shaped 
ones, 0.025-0.066 mm. Sago starch. 
The legumes, peas, beans (lima and white) show unmodified 
starch even after healthy digestion. In these, especially if not very 
much broken up, the seed coat prevents the full action of the 
digestive processes. The unripe seeds show a better digestion than 
the ripe ones, especially if the latter have been dried. In both 
pea and bean the epidermis cells and a row of bottle-shaped cells 
beneath are unaltered. These are strongly cutinized. 

From a practical point of view it is apparent that in digestive 
disturbances it is highly improbable that the green vegetables are 
of much value. Their food value is relatively low, and, in view 
of the fact that the microscope shows unaltered cell walls, it is 
probable that they are only admissible when given in a very 



200 



EXAMINATION OF THE FECES. 
Fig. 83. 




Bean flour. 1, to right, cross section of testa; Ep, epidermis palissade cells; H, hypo- 
derm with calcium oxalate crystals; P, parenchyma; 2, epidermis cells in flat; 3, 5, isolated 
palissade cells ; 4, hypoderm cells in profile ; 6, same seen flat ; 7, tissue of cotyledons. Left, 
1-4, cotyledon cells ; 5, reticulated parenchyma of seed coat; 6, starch. (Vogl.) 



MICROSCOPICAL EXAMINATION OF THE FECES. 201 

finely-divided condition. The outer coat of the pea, bean and 
cereals all come within this restriction particularly. 

Aleurone grains being very soluble in water are usually taken 
up readily, from the seeds of which, in many instances, almonds, 
they make the larger part. In blood serum aleurone grains do not 
seem to dissolve, and hence they are found in the feces after 
serous diarrheas and dysenteries in slightly altered form only. 
Up to the present time research has overlooked the aleurone grain 
very largely. 

Crystals of calcium oxalate are abundant in most food plants, 
being particularly rich in rhubarb, beet tops, tomatoes, spinach and 
many greens. Their fate is not entirely worked out. Many are 
dissolved in the acid gastric juice, particularly in hyperchlorhy- 
dria, and thus are absent in the stools, and appear as oxalates in 
the urine. They are found abundantly in the feces in those con- 
ditions in which cellulose disintegration is retarded, as they cannot 
escape from the plant cells in which they are imprisoned. Rosette 
crystals, rhomboids, and acicular varieties are those most com- 
monly met with. Rhubarb crystals are large rosettes. 

In normal feces the cutinized elements, notably the epidermis 
cells, with hairs and stomata, are readily recognized. They are 
rarely altered, especially if the epidermal walls are thickened. 
The same is true of the lignified elements in plant tissues. Those 
found in practically all plants are the ducts — spiral, reticulated 
and pitted. The presence of pitted and reticulated ducts in the 
feces invariably means that the vegetables have been over-ripe and 
old, becoming woody, as is often the case with beets, carrots, 
turnips, cucumbers, etc. In fresh, green vegetables practically 
only the more delicate spiral ducts are to be found. With increas- 
ing age the pitted and reticulated ducts appear. Celery invariably 
contains the stronger lignified ducts, and they are abundantly 
found in the feces after eating celery. 

From the diagnostic point of view, it is doubtful if, in our 
present state of knowledge, much can be learned of the digestive 
processes from the study of these lignified elements. The slight 
cellulose wall in the spiral vessels may be completely disinte- 
grated, freeing the more resistant spiral thickening, but this offers 
little help as an index to digestive function. 

Much concerning plant detritus may be gained from systematic 
microscopical examination of the feces, particularly from the 
medico-legal standpoint. Diagnosis of poisoning by many min- 
eral and vegetable poisons may be made thereby. This is partic- 



202 



EXAMINATION OF TEE FECES. 



Fig. 84. 




Oat flour. Ep, epidermis; Al, aleurone cells; Al 1 the same after treatment by NaOH; 
t, hairs; Am, starch; Sg, epidermis fragments; End, cells from endosperm. (Vogl.) 



MICROSCOPICAL EXAMINATION OF THE FECES. 203 

ularly true in the case of poisoning by the vegetable narcotic 
poisons, belladonna, aconite, etc., etc., The identification of 
these poisons rests on a thorough knowledge of the cell elements of 
the plants themselves. This lies outside of the scope of the pres- 
ent work, but reference may again be made to some of the works 
already mentioned, and also to Moeller's studies on the Forensic 
Importance of the Feces. 1 

1 Wieuer klin. Kundschau, 1897, No. 11, The standard Atlases of Pharmacog- 
nosy, Tschirch and Oerstele, Moeller, Koch, etc., are invaluable as reference works 
in this type of research. Jelliffe, Introduction to Pharmacognosy, 1904. 



CHAPTER XVI. 

BACTERIOLOGICAL EXAMINATION OF FECES. 

The bacteriological examination of feces is a very recent devel- 
opment of laboratory diagnosis, and may truly be said to be still 
in its infancy. Of the bacteria which occur in feces, only a very 
minute proportion are capable of isolation and artificial cultivation. 
It is often not possible to identify certain pathogenic forms, e. <g., 
the typhoid bacillus, even when they occur in the stools in very 
large numbers. As is usually the case under such circumstances, 
the number and variety of the methods which have been elaborated 
is in inverse proportion to the paucity of the results. It has been 
deemed best, therefore, to include in the following pages only 
those methods and only those conclusions which seem fairly firmly 
established, leaving aside all discussions in the many vexed prob- 
lems which have not as yet found a solution. 

Methods. — It is evident that if the feces are to be subjected 
to bacteriological examination, pains must be taken to obtain them 
in an uncontaminated condition. For this purpose, only freshly 
passed stools should be utilized, inasmuch as the bacterial flora is 
very much altered by standing. 

For infants, in whom the fecal matter is always soft, Escherich 
suggested the following device : The anus is thoroughly cleaned 
with some mild disinfectant, and a sterilized rod is then introduced 
into the rectum to irritate it; evacuations "produced under sterile 
precautions" are thus available at all times. Cohnheim devised a 
metal instrument of small caliber, carrying an eye at one end, 
which may be introduced into the infant's rectum, and carries 
away small samples in the eye. In adults, the hardness of the 
fecal mass defeats these measures. Here it is best simply to break 
open the fecal cylinder with spatula?, and remove material for 
examination from the interior. 

The first step in every examination of feces is the microscopical 
examination, either in the hanging drop, or in stained prepara- 
tions, or, preferably, both. This procedure ought never to be 
omitted, because it offers a far truer picture of the actual condi- 
tions than can ever be obtained by cultural work. Unfortunately, 

(204) 



BACTERIOLOGICAL EXAMINATION OF TEE FECES. 205 

the vast majority of the fecal bacteria do not grow on the artificial 
media, and would, therefore, entirely escape observation were the 
direct microscopical examination omitted. 

For hanging drop preparations, it is advisable always to dilute 
the fecal matter liberally with water. For stained preparations, 
the bacteria should be separated by centrifugation. A bit of feces 
half as large as a pea is rubbed up with a few cc. of water, 
and then centrifuged, whereby the bacteria are held in suspension, 
and the other material sinks to the bottom. The supernatant fluid 
is then diluted with twice its bulk of 95 per cent, alcohol, and again 
centrifuged; a sediment, which contains bacteria almost exclu- 
sively, is thus obtained. This is evenly distributed on a slide, 
either with an oese, or by Ehrlich's blood-smearing method, and 
is then stained. For routine work, the stains used are Loffler's 
methylen blue, or a 10 per cent, solution of carbolfuchsin. 

A very useful stain, especially in certain diseases of infancy, is 
the Gram stain, as modified by Weigert-Escherich (1. 5 grains 
gentian violet in 200 cc. of water, boiled one-half hour, and 
filtered. 2. 11 cc. absolute alcohol mixed with 3 cc. anilin 
oil. 3. Lugol's solution : 1 grain iodine, 2 grains potassium iodide, 
60 cc. water. 4. Anilin oil and xylol, aa. 5. Xylol). 

To stain: 8% parts of 1 and 1% of 2 are mixed, left on slide 
for one-half minute, and then dried with filter paper. Lugol's 
solution allowed, to rapidly flow over slide, then blotted. The slide 
is now treated with anilin xylol until no more blue clouds are given 
off, and then washed in xylol. As a counter stain, fuchsin may be 
used. 

For special bacteria, notably the tubercle bacillus, differential 
stains are in use* 

Cultural methods cannot be described here in detail, but must 
be sought in the general bacteriological text-books. Such methods 
as belong particularly to coprological diagnosis, e. g., the identifi- 
cation of typhoid germs, will be briefly described in connection 
with the bacteria. 

Normal Stool. — The meconium is, of course, at first sterile, 
but begins to show the presence of bacteria generally within ten 
to seventeen hours after birth. The flora is very diverse, consisting 
of numerous forms of cocci and bacilli, all of which are derived 
from the air. 

With the onset of the period of breast-feeding, the flora changes 
and becomes very characteristic. The smear contains almost exclu- 
sively long, slender bacilli, arranged often in parallel groups. 



206 EXAMINATION OF THE FECES. 

Stained with Gram, these bacilli have the remarkable property of 
retaining their blue color. They are composed, it appears of two 
varieties, an anaerobic known as Bacillus bifidus communis, and an 
aerobe known as Bacillus acidophilus. In addition, there are a 
few specimens of the Bacillus coll communis, Bacillus lactis 
cerogenes, and streptococci. 

In culture, unless very special precautions are taken, only the 
colon bacilli are found, and they occupy the plates practically in 
pure culture — an example of the very illusory picture which is 
often yielded by this method. 

When the infant is nursed on cow's milk, an altogether different 
flora is found. Many of the Gram-positive bacilli are still to be 
found, but there are, in addition, a vastly greater number* of 
Bacillus coli communis and Bacillus lactis cerogenes, the Entero- 
coccus and an ocasionally pathogenic coccus, the streptococcus of 
Hirsch-Libman, also Staphylococcus albus. 

The stool of adults presents a further development of that of 
artificially-fed children. The blue bacilli are vastly outnumbered 
by the Bacillus coli, however, and cocci are far more numerous. 
On a vegetable diet, the blue bacilli become more frequent, while 
on a meat diet there are more cocci. Yeast forms are also found. 

Bacterial System. — The number of varieties of bacteria which 
occur in the feces is legion. Of these a large proportion 
has not been identified. Many do not grow at all on ordinary 
media ; many seem to be obligate anaerobes. Moreover, the syste- 
matic determination and description of the forms hitherto de- 
scribed has generally been very lax, and unscientific, so that it has 
been extremely difficult to reidentify the species of authors from 
their own descriptions. 

Recently, in two publications of great importance ( Studies from 
the Royal Victoria Hospital, Montreal, Vol. I, No. 5, and Studies 
from the Rockefeller Institute for Medical Research, Vol. II), 
W. W. Ford has described, with great care and accuracy, a large 
number of forms which he found in bacteriological examination of 
the stomach and intestines. 

His work marks an epoch in this line of research, and must, for 
the present, be taken as the point of departure also for bacterio- 
logical examination of the feces. His descriptions have, there- 
fore, been adopted verbally, and a few forms, not described by him 
but found in the feces, have been inserted into his classification. 

The bacilli are divided as follows by Ford : 

a The first group of alkali-producers, on the one hand, is rep- 



[. Producing no acid. Producing no acid. 
B. pylori. 



Liquefying. 



Gelatine. 
Casein. 



Gelatine. 

Casein. 

Blood Serum. 

I 



Producing acid and gas with 



B. caeci. 
B. Bookeri. 



Booker group. 



Dextrose. 

Saccharose. 

Lactose. 



Dextrose. 
Lactose. 



Dextrose. 
Saccharose 



B. plebeius. B. infrequens. B. vulgaris 

Proteus or Hauser group. 



Liquefying. 



Gelatine. 

Casein. 

Blood Serum. 

I 



Producing acid. 



B. dutiius. 
B. jejunalis. 



Producing acid and gas with 



Dextrose. 
Saccharose. 
Lactose. 
I 
B. cloacae. 



Dextrose. 
Lactose. 



B. subcloacae. 



Dextrose. 
Saccharose. 



B. iliacus. 



Cloacae or Jordan group t 



iata do not include by any means all the organisms which are known to 
nisms actually found during- the progress of this investigation. A large 
it acid to coagulate milk— is not included, inasmuch as neither Bacillus 

:ali-producing liquefying bacteria, which have no action on carbohydrate 
oup " includes bacteria which produce acid, liquefy various media and 
>n on carbohydrates other than lactose. Both these extra groups are, 

ave been utilized. Not only are further combinations of carbohydrates 

rtain cases have already been cultivated from sources outside the human 

'Coli Group," but which is characterized by the fermentation of dextrose 

liquefying gelatine and casein but possessing the other features of these 



Non-liquefying. 



I 
^carbohydrate fermenting. 



B.alcaligenes. 

Fatcalis alcaligeties or 
Petruschky group. 



Producing acid. 

I 
B. pseudodysentericns. 

Dysenteric or Shiga 
group. 



NON- PIGMENT- PRODUCING. NON-SPOREBEARING, ALKALI -PRODUCING BACTERIA, 



Carbohydrate fermenting. 



Producing acid and gas with 



Dextrose. 

Saccharose. 

Lactose. 



Dextrose. 
Lactose. 



B. alcalescens. B. subalcalescens. B. enteritidis. Bact. 

galactophilum. 

Hog-cholera or Suipeslifer group. 



Gelatine. 

I 

1 



Producing acid and , 



Liquefying. 



Gelatine. 
Casein. 



Gelatine. 

Casein. 

Blood Serum. 



Dextrose. 

Saccharose. 

Lactose. 



with Producing no acid. Producing no acid. Producing no acid. 

I B. caeci. 

B. recti, B. pylori. B. Bookeri. 

™ e - Booker group. 



subentericus. 



Enteric us group. 



Producing acid and gas with 

I 



Dextrose. Dextrose. Dextrose. 

Saccharose. Lactose. Saccharose 
Lactose. 

B. plebeius. B. infrequens. B. vul<f ari s 



Proteus or Hauser group. 



NON -PIGMENT- PRODUCING, NON-SPOREBEARING, ACID -PRODUCING BACTERIA. 



Non-liquefying. 



Liquefying. 

I 



Non-carbohydrate fermenting. Carbohydrate fermenting. 



Bact. oxygenes. 
Bact. Bienstocki. 



Faecalis oxygenes or 
Bienstock group. 



Producing acic 



B. oxyphilus. 
Bact. acidoformans. 
Bact. mirmtissimum. 

Acidoformans or 
Sternberg group. 



d ai 



Producing acid and gas with 



Dextrose. 

Saccharose. 

Lactose. 

B. Coli. 
Bact. aerogenes. 



B. communior. 
Bact. duodenale. 



Co li or Escherich group. 



Producing acid and 



Dextrose. Dextrose. 

Saccharose. Lactose. 

Lactose. 

B. gastricns. B. snbgastricus. 

Bact. liquefaciens. Bact. subliquefaciens. 

Liquefa 



Producing acid. 

Bact. chylogenes. 
Bact. chymogenes. 



Producing acid 
B. leporis. 



I 

Producing acid. 

I 
B dubius. 
B. jejnnalis. 



Dubius or Eruse group. 



Gelatine. 

Casein. 

Blood Serum. 

I 



Producing acid and gas with 



Dextrose. 

Saccharose. 

Lactose. 

B. cloacae. 



Dextrose. 
Lactose. 



Dextrose. 
Saccharose. 



B. subcloacae. 



Cloacae or Jordan group, 



In considering the various groups into which the microorganisms of the intestine have been divided, it becomes at once apparent that these schemata do not include by any means all the organisms which are known 
forms which on a priori grounds m.ght be hypothecated. As a matter of fact they represent merelv the onanism, actually found during the progress of th 
of Bacillus typhosus are the type— organisms which are neither alkali-producers, n 



organisms aciuany iuuuu uuung the progress of this investigation. A large 
hich produce sufficient acid to coagulate milk— is not included, inasmuch as neither Bacillus 



exist in nature, nor a number of possible 

group of organisms, of which many cultures 

typhosus nor any allied bacilli were grown from the intestinal con en 

Several gaps, moreover, are apparent when the acid and f^^^^^^y^^' Jhus while the " Booker Group " includes alkali . pro ducing liquefying bacteria, which have no action on carbohydrate 
solutions, no provision whatever is made for alkali-producing Uquefymg bacteria wh«h spl.t up the sugars to the point of ac.d.ty. Similarly the «■ Kruse Group ' includes bacteria which produce 'acid, liquefy various media and 
ferment carhl-H^s ta th. noint of acidity, not including, however, closely alhed group of acid-producng liquefying organisms which have 



from a theoretical standpoint, perfectly possible. 

Again, under the various groups of organisms breaking 
available for still further differentiation of species, but — 
boc ly- Thus 1 have previously described (Ford, 1900) a 
a "d saccharose, but not lactose. Again, in the "Book 
groups, are likewise perfectly able to exist in nature. 



no action on carbohydrates other than lactose. Both these extra gr 



ips are, 




or g , anisms 
{From Food Studies at Rockefeller Institute for Medical Resear h 1 



Not only are further combinations of carbohydrates 

eady been cultivated from sources outside the human 

hich is characterized by the fermentation of dextrose 

fying gelatine and casein but possessing the other features of these 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 207 

resented by Bacillus alcaligenes of Petruschky, an organism which 
is characterized, as is already well known, by non-liquefaction of 
the proteids, by failure to ferment any sugars to the point of 
acidity and consequent limitation of the growth of the organism 
to the bulb of the fermentation tube; and by the immediate pro- 
duction of alkali in litmus milk. 

"Next to this group stands a group of very considerable impor- 
tance, and represented by Bacillus pseudodysentericus, the 'Dysen- 
teric Group/ characterized by non-liquefaction of proteids, by the 
fermentation of carbohydrates to the point of acidity and by an 
initial acidity in litmus milk followed by intense alkali-produc- 
tion. 

"This group will naturally be followed by a group embracing 
those organisms endowed" with the capacity of splitting up carbo- 
hydrates to the point of acidity and gas production, but agreeing 
with the previous organisms in non-liquefaction of proteids and in 
an initial acidity in milk followed by alkali-production. Such 
organisms are included in the Hog-cholera group, embracing 
Bacillus alcalescens, fermenting dextrose, saccharose and lactose ; 
Bacillus subalcalescens, fermenting dextrose and lactose ; Bacillus 
enteritidis, fermenting dextrose, and Bacterium galactopliilum, 
fermenting only saccharose and lactose. 

"Following the same line of argument, we next have organisms 
which likewise ferment the carbohydrates, produce an initial 
acidity in litmus milk, followed by alkali-production, and which 
are further endowed with the capacity of liquefying the proteids. 
In one group liquefying gelatine alone, the 'Entericus Group,' 
two organisms may be distinguished, the Bacillus entericus, fer- 
menting dextrose, saccharose and lactose, and Bacillus subentericus, 
breaking up dextrose and lactose. In another group, liquefying 
gelatine, casein and blood serum, the "Proteus Group, 7 three 
members may be made out: — -1st, Bacillus plebeius, fermenting 
dextrose, saccharose and lactose ; 2d, Bacillus vulgaris, breaking up 
dextrose and saccharose, and 3d, Bacillus infrequens, breaking up 
dextrose and lactose. 

"Finally a last group of organisms may be made out, character- 
ized by non-fermentation of carbohydrates, their growth being lim- 
ited to the open bulb of the fermentation tube, by immediate alkali- 
production in litmus milk and by the liquefaction of various 
media. In this group, the 'Booker Group' may be distinguished 
Bacillus recti, liquefying gelatine, Bacillus pylori, liquefying gela- 
tine and casein, and Bacillus cceci and Bacillus Bookeri, both lique- 
fying gelatine, casein and blood serum. 



208 EXAMINATION OF THE FECES. 

"In the same way the various acid-producing bacteria may 
be arranged in certain groups differing from each other by grada- 
tions in reactions similar to those seen with the alkali-producers. 
In the first group, the 'Bienstock Group/ may be placed organ- 
isms which occupy a position among the acid-producers analogous 
to that of Bacillus alcaligenes among the alkali-producers, in that 
its two members, Bacterium Bienstockii and Bacterium oxy genes, 
are both characterized by the acidification and coagulation of 
milk, the non-liquefaction of the proteids and the failure to pro- 
duce acid in carbohydrate solutions in the fermentation tube. 

"Next to this group comes a group with similar properties of 
acidification and coagulation of milk and non-liquefaction of 
proteids, but one in which the fermentation of the carbohydrates to 
the point of acidity occurs. This group is represented by three 
members, Bacterium minulissimum, Bacterium acidoformans and 
Bacillus oxyphilus. 

"Following the same sequence of characters, we next have non- 
liquefying organisms acidifying and coagulating milk, but fer- 
menting the carbohydrates to acid and gas production. The four 
members of this group, Bacillus coli, Bacillus communior, Bac- 
terium cerogenes and Bacterium duodenalis. These will be con- 
sidered at some length. This group occupies among the acid- 
producers a position similar to that filled by the Hog-Qholera 
group among the alkali-producing bacteria." 

Two groups of organisms next occur which are similar to the 
bacteria just mentioned in their acidification and coagulation of 
milk, and in their fermentation of the sugars, but which are 
capable of liquefying the carbohydrates. In the first group, lique- 
fying gelatine only, Bacillus gastricus and Bacillus subgastricus 
have been considered already, as well as the three members of the 
"Cloacse Group" which liquefy gelatine, casein and blood serum, 
namely, Bacillus cloacm, Bacillus subcloacce and Bacillus iliacus. 
Finally a second series of organisms follows which includes the 
various cultures acidifying and coagulating milk, breaking up 
carbohydrates to the point of acidity and liquefying various 
media. This group includes Bacterium* chylo genes and Bacterium 
chymogenes/ liquefying gelatine, Bacillus Icporis, liquefying gela- 
tine and blood serum, and Bacillus dubius and Bacillus jejunalis, 
liquefying gelatine, casein and blood serum. 

We thus may tabulate the various acid and alkali-producing 
bacteria of the human intestine which have been isolated, as 
follows : 



PLATE IX. 



FIO. 1. 



fiq. 2. 




/l000.'~ Diarrheal St0 ° 1S ° f ^ adUU ' Wlth l0ng ' rSd baeilli - Weigert-Eseherich stain. 

&^°SS! ^a^rin^// 1 " Chiefly ° f ™~*" CentMfugation as 
IVni^-nrs^asCgef 001 ' ^ * PPed °"^ *•« diet. Detaiis as in Pig. , From 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 209 

ALKALI-PRODUCERS. 

Group I. — Organisms producing alkali in litmus milk not 
liquefying any media, not fermenting carbohydrates to the point of 
acidity: — fjecalis alcaligenes, or peteuschky geoup. Rep- 
resented in the forms isolated by 

1. Bacillus alcaligenes, Migula, 1900. 

Geoup II. — Organisms producing alkali, not liquefying any 
media, fermenting carbohydrates to the point of acidity but no 
gas : — dysexteeicus or shiga geoup. Represented by 

2. Bacillus dysenterice. 

3. Bacillus pseudodysentei-icus, Aliiller, 1902. 
1. Bacillus typhi. 

5. Bacillus acidophilus. 

Geoup III. — Organisms producing alkali, not liquefying any 
media, fermenting the carbohydrates with the production of 
acidity and gas: — hog-choleea or suipestifee geoup. Repre- 
sented by 

6. Bacillus alcalescens, Ford, 1903 — Fermenting dextrose, 

saccharose and lactose. 

7. Bacillus subalcalescens, Ford, 1903 — Fermenting dextrose 

and lactose. 

8. Bacillus enteritidis, Gartner, 1888 — Fermenting dextrose. 

9. Bacterium galactophilum. Ford, 1903 — Fermenting sac- 

charose and lactose. 
Geoup IV. — Organisms producing alkali, liquefying gelatine, 
fermenting carbohydrates with the production of acid and gas: — 
exteeicus geoup. Represented by 

10. Bacillus entericus. Ford, 1903 — Fermenting dextrose, 

saccharose and lactose. 
11., Bacillus subentericus, Ford, 1903 — Fermenting dextrose 

and lactose. 
Geoup V. — Organisms producing alkali, liquefying gelatine, 
casein and blood serum, fermenting carbohydrates with the pro- 
duction of acid and gas: — peoteus or haesee geoup. Repre- 
sented by 

12. Bacillus plebeius, . Ford, 1903 — Fermenting dextrose, 

saccharose and lactose. 

13. Bacillus infrequens, Ford, 1903 — Fermenting dextrose 

and lactose. 

14. Bacillus vulgaris, (Hauser, 1885) Migula, 1900 — Fer- 

menting dextrose and saccharose. 



210 EXAMINATION OF THE FECES. 

Group VI. — Organisms producing alkali, liquefying various 
media, but not fermenting carbohydrates to the point of acidity : — 
booker group. Represented by 

15. Bacillus recti, Ford, 1903 — Liquefying gelatine. 

16. Bacillus pylon, Ford, 1903 — Liquefying gelatine and 

casein. 

17. Bacillus cwci, Ford, 1903 — Liquefying gelatine, casein 

and blood serum. 

18. Bacillus Bookeri, Ford, 1903 — Liquefying gelatine, casein 

and blood serum. 

19. Bacillus pyocyaneus. 

ACID-PRODUCERS. 

Group I. — Organisms acidifying and coagulating milk, not 
liquefying any media, not fermenting carbohydrates to the point 
of acidity: — fjecalis oxygexes or biexstock group. Repre- 
sented by 

20. Bacterium oxy genes, Ford, 1903. 

21. Bacterium Bienstockii, Schroter, 1886. 

Group II. — Organisms acidifying and coagulating milk, not 
liquefying any media, fermenting carbohydrates to the point of 
acidity but no gas : — acidoformans or Sternberg group. Repre- 
sented by 

22. Bacillus oxypliilus, Ford, 1903. 

23. Bacterium acidoformans, Sternberg, 1892. 

24. Bacterium minutissimum, Migula, 1900. 

Group III. — Organisms acidifying and coagulating milk, not 
liquefying any media, fermenting carbohydrates with the produc- 
tion of acidity and gas : — coli or escherich group. Represented 

by 

25. Bacillus coli, Migula, 1900 — Fermenting dextrose and 

lactose. 

26. Bacillus communior, Ford, 1903 — Fermenting dextrose, 

saccharose and lactose. 

27. Bacterium aerogenes, Migula, 1900 — Fermenting dex- 

trose, saccharose and lactose. 

28. Bacterium duodenale, Ford, 1903 — Fermenting dextrose 

and lactose. 
Group IV. — Organisms acidifying and coagulating milk, lique- 
fying gelatine and fermenting the carbohydrates with the produc- 
tion of acidity and gas : — liquefaciens or eisexberg group. 
Represented by 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 211 

29. Bacillus gastricus, Ford, 1903 — Fermenting dextrose, sac- 

charose and lactose. 

30. Bacillus subgastricus, Ford, 1903 — Fermenting dextrose 

and lactose. 

31. Bacterium liquefaciens, (Eisenberg, 1892),. Ford, 1903 — 

Fermenting dextrose, saccharose and lactose. 

32. Bacterium subliquefaciens, Ford, 1903 — Fermenting 

dextrose and lactose. 
Group V. — Organisms acidifying and coagulating milk, lique- 
fying gelatine, casein and blood serum and fermenting the carbo- 
hydrates with the production of acidity and gas: — cxoacje or 
Jordan group. Represented by 

33. Bacillus cloacae, Jordan, 1896 — Fermenting dextrose, 

saccharose and lactose. 

34. Bacillus sub cloacae, Ford, 1903 — Fermenting dextrose and 

lactose. 

35. Bacillus iliacus, Ford, 1903 — Fermenting dextrose and 

saccharose. 
Group VI. — Organisms acidifying and coagulating milk, lique- 
fying various media, fermenting the carbohydrates with the pro- 
duction of acid, but no gas: — dubius or kruse group. Repre- 
sented by 

36. Bacillus chylogenes, Ford, 1903 — Liquefying gelatine. 

37. Bacterium chymogenes, Ford, 1903 — Liquefying gelatine. 

38. Bacillus leporis, Migula, 1900 — Liquifying gelatine and 

blood serum. 

39. Bacillus dubius, Kruse, 1896 — Liquefying gelatine, 

casein and blood serum. 

40. Bacillus jejunalis, Ford, 1903 — Liquefying gelatine, 

casein and blood serum. 
The following pigment-producing and spore-bearing organisms 
have been isolated : 

41. Pseudomonas aeruginosa (Schroter, 1872), Migula, 1900. 

42. Pseudomonas ovalis (Ravenel, 1896), Chester, 1901. 

43. Bacterium Hav aniens e (Sternberg, 1892), Chester, 1901. 

44. Bacterium lutescens, Migula, 1900. 

45. Bacterium anthracoides (Hueppe & Wood, 1881), Mig- 

ula, 1900. 

46. Bacterium implectans, Burchard, 1898. 

47. Bacillus cereus, Frankland, 1887. 

48. Bacillus mycoides, Fliigge, 1886. 



212 EXAMINATION OF THE FECES. 

49. Bacterium lacticola, Migula, 1900. 

50. Bacterium vermicular e (Frankland, 1889), Migula, 1900. 

51. Bacillus vulgatus, Trevisan, 1889. 

52. Bacillus brevis, Migula, 1900. 

53. Bacillus subtilis, (Ehrenberg, 1833), Colm, 1872. 

54. Bacillus arachno ideus, Migula, 1900. 

1. BACILLUS ALCALIGENES, Migula, 1900. 

Literature and Synonyms: Bacillus fwcalis alcaligenes. — 
Petruschky, 1896, Bacillus faecalis alcaligenes (n.sp). Cen- 
tralblatt fiir Bakteriologie, Parasitenk. u. Infektionskr., Vol. 
XIX, p. 187 (not Bacillus fee xalis, Kruse, 1896). 
Bacillus alcaligenes (Petruschky) Migula, 1900. — Migula, 

1900, System der Bakterien, p. 737. 
Bacillus alcaligenes Petruschky — Chester, 1901, Manual of 
Determinative Bacteriology, p. 218. 

First isolated by Petruschky from typhoid stools. 

Morphology. — Bacilli resembling Bacillus typhosus in morphol- 
ogy, measuring 0.5 by 1-2 microns in dimensions, often 
growing in pairs and in long filaments made up of individual 
bacilli. 

Motility. — Actively motile, especially in old cultures. 

Spores. — Xot formed. 

Agar Slant — White, glistening growth limited to line of inocula- 
tion, not spreading nor sloping. 

Agar Colonies. — Deep colonies, round, uniform, opaque; super- 
ficial colonies, usually transparent, circumscribed, but may 
spread slightly, showing opaque centers and slightly thinner 
edges, often assuming diverse shapes. 

Broth.— Heavy thick scum on the surface, the broth itself being 
fairly clear and often free from sediment. 

Gelatine Stab. — Abundant growth along line of inoculation. No 
liquefaction. 

Gelatine Colonies. — Deep .colonies, round and regular; superficial 
colonies, round, translucent, with nail-form appearance. 

Potato. — Growth varies from a scanty white to an abundant dirty- 
yellowish or brownish mass covering entire surface of potato. 
Growth rarely reddish brown. 

Fermentation Tube: Dextrose Broth. — Growth limited to open bulb 
where a thick, heavy scum is formed on the surface, and a 
heavy sediment settles down to the branch. Reaction in bulb, 
alkaline. Xo growth in closed arm. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 213 

Saccharose and Lactose not fermented to acid or acid and 
gas. 

Blood Serum. — Abundant white or yellowish brown growth along 
line of inoculation. No liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Produced rarely in old cultures. 

Fecal Odor. — Rare, may appear in old cultures. 

Litmus Milk: Characteristic Reaction. — Production of alkali im- 
mediate ; within forty-eight hours milk turns bine ; no stage of 
preliminary acidity; alkali-production continues for some 
days. No coagulation of the milk. After neutralization of 
the alkali with weak acid the casein is found undissolved. 

Pathogenicity. — Xon-pathogenic to mice, guinea-pigs or rabbits. 

Occurrence and Distribution. — Found in fourteen cases of fifty 
examined. Found in rectum alone in five cases, in cecum 
alone in two cases, in duodenum alone in three cases. Pound 
in combination, in rectum and stomach, in rectum and duode- 
num, in cecum and duodenum and in duodenum and stomach. 
It is thus seen to be commonly present in the lower portions of 
the intestinal tract, more rarely appearing in the upper part 
of the bowel. 

2. BACILLUS DYSENTERIC, Shiga, 1898. 

Literature. — Iv. Shiga. Centralblatt fur Bakteriologie, Parasiten- 
kunde, und Infectionskrankheiten, 1898, Vol. XXIV. 

Strong and Musgrave. Preliminary Xote regarding the Eti- 
ology of the Dysenteries of Manila. Report of the Surgeon-Gen- 
eral of the Army, Washington, 1900, p. 251. 

S. Flexner. On the Etiology of Tropical Dysentery. Bulletin 
Johns Hopkins Hospital. 1900, p. 231. 

Vedder and Duval. The Etiology of Acute Dysentery in the 
United States. Journal of Experimental Medicine, Vol. VI, p. 
181. 

In all characters, Bacillus dysenteriw resembles form Xo. 3. It 
differs, however, in the serum reaction, inasmuch as it does agglu- 
tinate with immune serum. 

3. BACILLUS PSEUDODYSENTERICUS, Mu'ller, 1902. 

Literature. — Kruse, 1901, Weitere Enter suchungen iiber die Ruhr 
und die Ruhrbaeillen, Deutsche med. Wochenschrift, Xos. 23 
and 24. 



214 EXAMINATION OF THE FECES. 

Ford, W. W., 1901, Classification of Intestinal Bacteria, 

Journ. of Medical Besearch, Vol. I, p. 211. 
Miiller, Paul Theodore, 1902, Ueber den bakteriologischen 
Befund bei einer Dysenterieepidemie in Sudsteiermark, 
Centralblatt fiir Bakteriologie, Vol. XXXI, 'No. 12, p„ 
558. 
First isolated by Kruse in "Pseudodysenterie'' and by Ford 
from normal intestinal contents. 

Morphology. — Bacilli measuring 0.5 by 1-2 microns in dimensions, 
growing in pairs and in short chains. 

Motility. — Slowly motile in young agar and broth cultures, motil- 
ity more marked in old cultures. 

Spores. — Xot formed. 

Agar Slant. — White, glistening growth along line of inoculation ; 
no tendency to spread or slope. 

Agar Colonies. — Deep colonies, round, regular and opaque; super- 
ficial colonies may be round, regular, finely granular, trans- 
lucent, with clean-cut margins, or present dark centers with 
slightly spreading periphery. The latter may spread over 
the surface of the agar, assuming various bizarre shapes. The 
formation and appearance of particular colonies cannot be 
associated with particular cultures, as transfers from one 
variety of colonies will later originate other varieties. The 
regular non-spreading colonies resemble those of Bacillus 
typhosus. 

Broth. — Luxuriant growth with the production of a heavy sedi- 
ment; no pellicle. 

Gelatine Stab. — Abundant growth along line of inoculation, 
spreading slightly on the surface of the gelatine ; no liquefac- 
tion. 

Gelatine Colonies. — Deep colonies round, regular and opaque; 
superficial colonies translucent, finely granular, spreading 
like those of Bacillus typhosus. 

Potato. — Luxuriant yellowish brown or brown growth. 

Fermentation Tube: Dextrose Broth. — Characteristic reaction. 
Abundant growth in bulb with a thick sediment settling down 
to the branch. No pellicle. Reaction Acid. Growth extends 
into closed arm where the broth speedily becomes turbid. 
Reaction ol closed arm acid; no production of gas. 

Saccharose and Lactose not broken up with the produc- 
tion of acid or gas. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 215 

Blood Serum. — Abundant white or yellowish-white growth, no 
liquefaction. 

Growth never becomes red. 

Nitrates. — Reduced to nitrites. 

Indol. — Produced rarely in small quantities. 

Fecal Odor. — Not produced. 

Litmus Milk. — Characteristic reaction. Transient acidity pro- 
duced within first twenty-four hours, yielding to a continuous 
alkali-production which turns the litmus milk blue. No coag- 
ulation of the milk. Neutralization shows undissolved 
casein. 

Pathogenicity. — Mice, guinea-pigs and rabbits die after subcuta- 
neous inoculation within twenty-four to forty-eight hours of a 
. septicemia. Bacilli in pure culture may be obtained from 
the internal organs. 

Occurrence and Distribution. — Found in ten different cases. Pres- 
ent in rectum in four cases, in cecum in one, and in stomach 
in one. Found in combination in four cases, in rectum and 
cecum twice, in cecum and duodenum and in cecum, duode- 
num and stomach. It is thus seen to be present especially in 
the lower portions of the bowel, but also to appear in the 
stomach as well. 

Serum Reactions. — Does not agglutinate with the blood serum of 
patients suffering from dysentery. 

4. BACILLUS TYPHI, Eberth. 

Literature and Synonyms: Bacillus typhosus. — Kruse, Fliigge. 
Losener, Arbeiten aus dem kaiserlichen Gesundheitsamt, 
Berlin, 1885, contains a full bibliography of 089 titles. 

Morphology. — In the organs generally short, thick bacilli (1.0- 
32 microns long, 0.6-0.8 broad), rarely short threads. In 
cultures, all varieties from short bacilli to long threads. 

Motility. — The bacilli and the threads are both actively motile. 
Flagella 8-14. 

Spores. — Not formed. Polar bodies once regarded as spores do 
not belong in this category. 

Agar Slant. — Fairly broad growth, whitish, gray, glistening, sur- 
face apparently perforated in places, sharp margins. Water 
of condensation clear, little sediment. 

Agar Stab. — Thread-like, at times somewhat granular, gray. Sur- 
face irregularly rounded, margins regular, grayish, then yel- 
lowish, glistening. 



216 EXAMINATION OF THE FECES. 

Broth. — Turbid, moderate sediment, which becomes homogene- 
ously distributed on shaking. 

Gelatine Stab. — Growth along line of inoculation, slightly gran- 
ular. Surface growth thin, white, grayish green, opalescent, 
transparent, rounded irregular margins, very slightly ele- 
vated. 

Gelatine plates. — Superficial colonies, at first small, yellowish, 
pin-point in size, soon growing larger, rounded, with irregu- 
lar margins, marginal zone lighter, transparent, grayish, 
while the center becomes whitish and opaque. Deeper colo- 
nies, rounded or yellowish. 

Potato. — Extremely delicate, moist, often almost invisible pellicle, 
which covers almost the entire surface of the potato. The 
growth to be typical should be on potatoes presenting an acid 
reaction. 

Fermentation Tube. — Growth abundant, sediment, reaction acid, 
no gas. • 

Dextrose Broth. — Lactose broth, similar reaction. 

Blood Serum. — Fairly abundant, grayish- white growth, no lique- 
faction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not formed. 

Fecal Odor. — Not produced. 

Litmus Milk. — No coagulation, very small amount of acid pro- 
duced. 

Pathogenicity. — Laboratory animals die after large doses of a 
septicemia ; similar symptoms produced by filtered cultures. 
Gradually increased doses produce immunity, with agglutina- 
tion reaction in serum. Chantemesse and Widal have suc- 
ceeded in growing a type which produces true typhoid, clin- 
ically and pathologically, in rabbits and apes. 

Serum Reactions. — Agglutinates in most cases with serum in 
dilutions of 20-100 of patients. 

5. BACILLUS ACIDOPHILUS, Moro, 1900. 

Literature. — Moro, Em Beitrag zur Kenntniss der normalen 
Darmbacterien des Sauglings. Jahrbuch fur Kinclerheil- 
kunde, Yol. LII. Also, Ueber die nach Gram farbbaren 
Bacillen des Saiiglingstuhles, Wiener klinische Wochenschrift, 
1900, No. 5. 

Morphology. — Rods measuring 1.5-2 micra in length, 0.6-0.9 
micra in breadth. Extremities slightly tapering, and some- 
what rounded. Occur irregularly, or in parallel groups. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 217 

Staining Reactions. — Gram positive. 

Motil ity. — Non-motile. 

Agar Slant. — Very poor growth. 

Potato. — No growth. 

Fermentation Tube. — Acidity, but no gas. 

Other Media. — Grows best on beer-wort bouillon, and in bouillon 
when acidified with acetic acid or a mineral acid, so that 
10 cc. are neutralized by 1 cc. of normal soda. 

Occurrence. — In the stools of breast infants. 

6. BACILLUS ALCALESCENS, Ford, 1903. 
Literature. — Ford, W. W., 1901, Classification of Intestinal 

Bacteria, Journal of Medical Research, Vol. I, p. 211. 

First isolated from intestinal contents and described by 
Ford. 
Morphology. — Bacilli measuring 0,.5 by 1 to 2 microns, usually 

appearing as single individuals, but occasionally growing in 

long chains. 
Motility. — Actively motile. 
Spores. — Not formed. 
Agar Slant. — White translucent growth, either limited to line of 

inoculation or spreading rapidly from this line within forty- 

.eight hours, covering the whole agar slant and sloping to the 

bottom of the tube. 
Agar Colonies. — Deep colonies round, regular, opaque ; superficial 

colonies have opaque white centers with spreading translu- 
cent periphery. 
Broth. — Turbidity and sediment, no formation of pellicle. 
Gelatine Stab. — Abundant growth along line of inoculation, and 

on the surface of the gelatine. No liquefaction. 
Gelatine Colonies. — Deep colonies, round, regular; superficial 

colonies have dark opaque centers and spreading peripheries. 
Potato. — Growth varies from a scanty yellowish- white to an 

abundant dirty-brown mass. 
Fermentation Tube: Dextrose Broth. — Abundant growth in bulb 

with the formation of a heavy sediment. Reaction in bulb, 

acid. Growth in closed arm with the evolution of gas and 

the production of acidity. 

Saccharose and Lactose also fermented with the produc- 
tion of acid and gas. 
Blood Serum. — Abundant opaque white growth. No liquefaction. 
Nitrates. — Reduced to nitrites. 



218 EXAMINATION OF THE FECES. 

Indol. — Rarely produced. 

Fecal Odor. — Rarely produced. 

Litmus Milk. — Preliminary acidity yielding in forty-eight hours 

to an intense alkali-production; no coagulation of the milk; 

no peptonization of the casein. 

7. BACILLUS SUBALCALESCENS, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
Isolated from intestinal contents and described by Ford. 
This organism differs from the preceding only in its failure to 
ferment saccharose — dextrose and lactose alike being broken up 
with the production of acid and gas. In its colony formation and 
in its cultural features it is identical with the organism just 
described. Several cultures were obtained from four cases where 
it appeared twice in the rectum, once in the cecum and once in the 
duodenum. 

8. BACILLUS ENTERITIDIS, Gartner, 1888. 
Literature. — Gartner, 1888, Ueber die Fleischvergiftung in 
Frankenkausen am Kyffhauser und den Erreger Desselben. 
Corresp. d. allg. Arztl. Vereins Thuringen Xo. 9. 
Migula, 1900, System der Bakterien, p. 714. 
Chester, 1901, Manual of Determinative Bacteriology, p. 
207. 
First isolated and described by Gartner in epidemics of 

meat poisoning. Identical culturally with, 
Bacillus paracolon, Widal, 1897, La Semaine Medicale, 

August 4th. 
Bacillus paracolon, Gwynn, 1898, Johns Hopkins Hos- 
pital Bulletin, March, p. 54. 
Bacillus O., Cushing, 1900, ibid., July, August, p. 157. 
Bacillus icteroides, Sanarelli, 1897, British Medical 
Journal, July 3d; 1898, Centralblatt fur Bakterio- 
logie, 29, p. 376. 
Bacillus paratijhpoid, Schottmuller, 1901. Zeitschrift 
fiir Hygiene, Vol. XXXVI, p. 368. 
Morphology. — Bacillus measuring 0.5 by 1.5 to 2 microns, appear- 
ing either as single elements, as pairs, or as short chains. 
Motility. — Actively motile. 
Spores. — Xot formed. 

Agar Slant — Grayish-white growth along line of inoculation 
without tendency to spread or slope. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 219 

Agar Colonies. — Deep colonies, round, regular, uniform and 
opaque; superficial colonies, round, translucent, with dark 
nucleus — not spreading. 

Broth. — Turbidity, no scum. 

Gelatine Stab. — Abundant growth, no liquefaction. 

Gelatine Colonies. — Deep colonies regular brown, superficial col- 
onies, round, gray, translucent, granular. 

Potato. — Abundant brown or yellowish-brown growth. 

Fermentation Tube: Dextrose Broth. — Abundant growth in bulb 
with heavy sediment; reaction acid. Growth in closed arm, 
abundant evolution of gas; reaction of closed arm acid. 
Saccharose and Lactose not fermented. 

Blood Serum. — Abundant dirty-white growth; no liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — Preliminary acidity yielding to alkali-production 
within forty-eight hours ; no coagulation. No peptonization 
of casein. 

9. BACTERIUM GALACTOPHILUM, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 

First isolated from intestinal tract and described by 
Ford. 

Morphology. — Bacteria measuring 0.75 by 1.5 microns, appearing 
in single elements. 

Motility. — Non-motile. 

Spores. — Not formed. 

Agar Slant. — Raised, viscid, sweaty growth, spreading along line 
of inoculation, but not sloping to bottom of tube. When 
touched with platinum needle long threads are brought away. 

Agar Colonies. — Colonies vary in size, are usually round, project 
from the surface, are dull-white in color, appearing not unlike 
drops of sweat. 

Broth. — Turbidity, scum on the surface and an abundant sedi- 
ment. 

Gelatine Stab. — Abundant growth, no liquefaction. 

Gelatine Colonies. — Deep colonies, round and regular ; superficial 
colonies irregular, skein-like with spreading processes. 

Potato. — Abundant dull white growth. 

Fermentation Tube: Dextrose Broth. — Thick scum and heavy sed- 



220 EXAMINATION OF TEE FECES. 

iment in bulb, no growth in closed arm ; reaction in bulb alka- 
line. Dextrose not broken up.. 

Saccharose and Lactose both fermented with the produc- 
tion of acid and gas. 

Blood Serum: — Abundant white growth, no liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — Preliminary acidity followed by intense alkali-pro- 
duction. No coagulation. No peptonization of the casein. 

10. BACILLUS ENTERICUS, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 

First isolated from intestinal contents and described by 
Ford. 

Morphology. — Bacilli measuring 0.5 by 1.5-3.0 microns, often 
growing out into long chains. 

Motility. — Actively motile. 

Spores. — Not formed. 

Agar Slant. — White, glistening growth, spreading oyer the sur- 
face of agar, and when specially luxuriant sloping to the bot- 
tom of the tube, where it forms a thick, heavy mass. 

Agar Colonies. — Deep colonies, round, regular, opaque ; superficial 
colonies have white opaque centers and slightly-spreading 
peripheries. Colonies never spread as much as those of 
Bacillus vulgaris, and are easily distinguished from them. 

Broth. — Marked turbidity, no scum. 

Gelatine. — Rapid liquefaction from surface downward ; within 
twenty-four hours a thick rim of liquefied gelatine is pro- 
duced and by the end of the fifth day the entire mass of 
gelatine is transformed to a thin fluid. 

Gelatine Colonies. — Small, round, regular, translucent colonies, 
often in rouleaux and giving a "broken glass" appearance. 

Potato. — Luxuriant dirty-brown growth spreading rapidly over 
the surface of the potato. 

Fermentation Tube: Dextrose Broth. — Turbidity in bulb; heavy 
sediment ; acid reaction; growth in closed arm; acid reaction 
and evolution of gas. 

Saccharose and Lactose also split up into acid and gas. 

Blood Serum. — Thick white growth, no liquefaction. 

Nitrates. — Reduced to nitrites. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 221 

Indol. — Produced, often in large quantity. 

Fecal Odor. — Rarely produced. 

Litmus Milk. — Preliminary acidity followed by intense alkali- 
production. No liquefaction. Upon neutralization casein 
found undissolved. 

11. BACILLUS SUBENTERICUS. Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
Organism similar to Bacillus entericus in the majority of their 
reactions, but failing to ferment saccharose were isolated in two 
cases. They represent a sub-species of this micro-organism. They 
were present i n the stomach of one case and in the cecum of 
another. 

12. BACILLUS PLEBEIUS, Ford, 1903. 

Literature. — Ford, W. W., 1901,* Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 

Morphology. — Bacilli 0.5 by 1.5-3.0 microns appearing in pairs or 
in long chains. 

Motility. — Actively motile, especially in old cultures. 

Spores. — Not formed. 

Agar Slant. — White glistening abundant layer spreading over the 
surface of agar and sloping to bottom of tube. 

Agar Colonies. — Deep colonies round or oval, brown in color; 
superficial colonies have opaque white centers and spreading 
translucent peripheries with frequent branching threads. 
Colonies may assume various bizarre shapes. 

Broth, — Marked turbidity. Rarely the production of a delicate 
film on the surface. 

Gelatine. — Abundant growth along line of inoculation ; rapid and 
complete liquefaction of gelatine beginning at the surface and 
proceeding downward. 

Gelatine Colonies. — Spreading colonies with dark opaque centers 
and lighter periphery. Rapid liquefaction about the individ- 
ual colonies. 

Potato. — Abundant yellowish-white or creamy-white growth turn- 
ing brown or red in old cultures. 

Fermentation Tube : Dextrose Broth, — Marked turbidity and sedi- 
ment in open bulb; rapid growth in closed arm with produc- 
tion of a large quantity of gas. Reaction in bulb and closed 
arm acid. 

Gas and acid also from Saccharose and Lactose. 



222 EXAMINATION OF TEE FECES. 

Blood Serum. — Abundant growth; slow but complete liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Rarely produced. 

Fecal Odor. — Not produced. Odor of putrefaction common to 
this group. 

Litmus Milk. — Preliminary acidity followed by intense alkali- 
production. No coagulation of the milk. Slow digestion of the 
casein which, after eight to ten days, is completely dissolved. 
Reduction of the litmus takes place at the same time, the 
resulting fluid being clear, transparent, soapy, with small 
drops of oil floating on the surface. Neutralization shows the 
complete peptonization of the casein. 

13. BACILLUS INFREQUENS, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
Organisms differing from the preceding form in their failing 
to ferment saccharose, but agreeing with it in their main 
cultural features may conveniently be grouped together 
under the name Bacillus infrequens. 
This form was obtained by Ford in nine cases, in rectum 
once, in cecum once, in duodenum three times and in com- 
bination in rectum and cecum once, in rectum and stomach 
twice, and in duodenum and stomach once. It is thus more 
frequently met with in the upper portions of the alimentary 
canal, being especially common to the duodenum. 

14. BACILLUS VULGARIS (Hauser, 1885), Migula, 1900. 

Literature and Synonyms: Proteus vulgaris. — Hauser, 1885, 
Ueber Faulniss-bacterien, Leipzig. 
Bacillus proteus. — Trevisan, 1889, Genera. 
Bacillus vulgaris. — (Hauser) Migula, 1900, System der 

Bakterien, p. 707. 
Bacillus vulgaris (Hauser), Chester, 1900, Manual of Deter- 
minative Bacteriology, p. 211. 

First isolated from putrefying masses by Hauser. 

Morphology. — Bacilli 0.5-1.0 by 1.0-3.0 microns in dimensions, 
appearing in pairs, but frequently in long chains. Great 
diversity in morphological appearance, the individual ele- 
ments frequently looking like micrococci, or very stumpy 
bacilli. 

Motility. — Young cultures show sluggish motility, old cultures 
often show active motility. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 223 

Spores. — ISTot formed. 

Agar Slant. — Thin bluish-gray growth, spreading rapidly over the 
surface of the agar and sloping to the bottom of the tube. 

Agar Colonies. — Typical spreading colonies with opaque white 
centers and outlying bluish-gray periphery. Deep colonies, 
round or oval, brown in color. 

Broth.-- — Turbidity marked, rarely a scum. 

Gelatine. — Abundant growth; rapid and complete liquefaction, 
beginning at the surface and extending downwards along line 
of inoculation. 

Gelatine Colonies. — Irregular spreading colonies with rapid lique- 
faction of the gelatine about them. 

Potato. — Abundantly yellowish-white, or creamy-white growth, 
turning brown in old cultures. 

Fermentation Tube: Dextrose Broth. — Rapid growth with produc- 
tion of a heavy sediment. Growth in closed arm. Abundant 
gas. Acid reaction, in bulb and branch. 

Saccharose broken up into acid and gas. 
Lactose not affected by this bacillus. 

Blood Serum. — Abundant growth. Slow and complete liquefac- 
tion. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. Putrefactive odor common. 

Litmus Milk. — -Preliminary acidity followed by intense alkali- 
production with peptonization of the casein and reduction of 
the litmus. Usually a soft coagulum is produced. After ten 
days milk transformed to a thin, colorless liquid with a few oil 
drops floating on the surface. 

15. BACILLUS RECTI, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 

First obtained from intestinal contents and described by 
Ford. 

Morphology. — Bacilli measuring 0.5 by 1.5-2.0 microns, occurring 
usually in pairs and chains. 

Motility. — Actively motile. 

Spores. — Xot formed. 

Agar Slant. — Grayish-white growth limited to line of inoculation, 
not spreading or sloping. 



224 EXAMINATION OF THE FECES. 

Agar Colonies. — Deep colonies, round, regular, uniform; super- 
ficial colonies very large, have opaque centers and very 
slightly spreading edges without branching. 

Broth. — Turbidity; no scum. 

Gelatine. — Rapid and complete liquefaction along line of inocula- 
tion. 

Gelatine Colonies. — Round or oval colonies, brown in color with 
great variations in size and shape. 

Potato. — Luxuriant brownish-red growth. 

Fermentation Tube: Dextrose Broth. — Turbidity in open bulb to 
which the growth is limited ; no growth in closed arm. Reac- 
tion of bulb alkaline. 

Saccharose and Lactose not fermented. 

Blood Serum. — Abundant white glistening growth without lique- 
faction. - 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — No preliminary acidity. Immediate alkali-pro- 
duction. No coagulation of the milk. No peptonization of 
the casein. 

16. BACILLUS PYLORI, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 

Bacteria, Journal of Medical Research, Vol. I, p. 211. 
First obtained from intestinal contents by Ford. 
Morphology. — Large bacilli measuring 1.0 by 3.0-4.0 microns, 

never appearing in chains. 
Motility. — Very actively motile. Bacilli shoot rapidly from one 

portion of the field to another with the velocity of a cholera 

vibrio. 
Spores. — Not formed. 

Agar Slant. — Spreading white translucent growth. 
Agar Colonies. — Deep colonies round and regular; superficial 

colonies spread over the surface with opaque white centers 

and outlying edges. 
Broth. — Turbidity, no scum. 
Gelatine Stab. — Abundant growth. Rapid liquefaction from 

surface downward. 
Gelatine Colonies. — Deep colonies round and regular; superficial 

colonies grayish with dark opaque centers and outlying 

translucent ring not spreading. 



BACTERIOLOGICAL EXAHIXATIOX OF THE FECES. 225 

Potato. — Luxuriant dull white growth. 

Fermentation Tube: Dextrose Broth. — Growth limited to open 
bulb where a heavy sediment is produced. No growth in 
closed arm. Reaction of bulb alkaline. 

Saccharose and Lactose not broken up. 

Blood Serum. — Abundant white growth, no liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Xot produced. 

Litmus Milk. — Preliminary acidity followed by alkali-produc- 
tion. No coagulation of the milk. Rapid peptonization of 
the casein and reduction of the litmus. 

17. BACILLUS (LECI, Ford, 1903. 

Literature. — Ford, W. W., 1901; Classification of Intestinal 
Bacteria, Journal of Medical Eesearch, Vol. I, p. 211. 
First obtained from intestinal contents by Ford. 

Morphology. — Long thick bacilli measuring 0.75 by 2.0-.4.0 
microns, usually growing in long chains. 

Motility. — Very sluggishly motile. 

Spores. — Not formed. 

Agar Slant. — Brown sweaty growth along line of inoculation 
without spreading or sloping. 

Agar Colonies. — Opaque, round, non-spreading colonies. 

Broth. — Turbidity and rarely the production of a scum... 

Gelatine Stab. — Abundant growth along line of inoculation. 
Rapid and complete liquefaction. 

Gelatine Colonies. — Irregular brown colonies, often associated in 
long rouleaux and cork-screws. 

Potato. — Luxuriant yellowish-white growth. 

Fermentation Tube: Dextrose Broth. — Growth limited to open 
bulb where a great turbidity is produced. No growth in 
closed arm; reaction alkaline. 

Saccharose and Lactose not broken up. 

Blood Serum. — Abundant yellowish-white growth and a slow but 
complete liquefaction. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — No preliminary acidity. Intense alkali produc- 
tion. No coagulation. Rapid liquefaction of casein. 



226 EXAMINATION OF THE FECES. 

18. BACILLUS BOOKERI, Ford, 1903. 

Literature and Synonym. — Bacillus A. Booker. Sternberg, 1896, 

Manual of Bacteriology, p. 492. 

First isolated from alvine discharges of children suffer- 
ing with cholera infantum, by Booker. 
Morphology. — Small bacilli measuring y 2 x iy 2 to 2 mikrons. 
Motility. — Actively motile. 
Spores. — Not formed. 
Agar Slant. — Abundant yellowish or yellowish-brown growth 

along line of inoculation, not spreading or sloping. 
Agar Coloyiies. — Deep colonies, round, regular, opaque ; superficial 

colonies have opaque centers and transparent thin film in 

periphery, which gradually merges with surrounding agar, 

giving an indistinct bluish look. 
Broth. — Marked turbidity, no scum. 
Gelatine. — Abundant growth along line of inoculation ; slow but 

complete liquefaction along line of puncture. 
Gelatine Colonies. — Round brown colonies of various sizes. 
Potato. — Luxuriant yellowish- white growth. 
Fermentation Tube: Dextrose Broth. — Abundant growth in open 

bulb, with the production of a heavy sediment. No growth in 

closed arm. Alkaline reaction in bulb. 

Saccharose and Lactose also not broken up. 
Blood Serum. — Yellowish-brown growth. Gradual liquefaction. 
Nitrates. — Not reduced to nitrites. 
Indol. — Not produced. 
Fecal Odor. — Not produced. 

Litmus Milk. — No preliminary acidity. Intense alkali-produc- 
tion. No coagulation. Slow and complete liquefaction of the 

casein with reduction of the litmus. 

19. BACILLUS PYOCYANEUS. 

Morphology. — Small bacilli measuring 1-2 by 0.3-0.5 micra. 
Usually single, sometimes in short chains. 

Motility. — Actively motile, monotrichous. 

Spores. — Absent. 

Agar Slant. — Rich, moist growth. 

Gelatine. — Colonies of irregularly-rounded contour, yellowish- 
green ; liquefied. 

Broth, — Clouded. 

Potato. — Dry growth. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 227 

Milk. — Coagulated and peptonized in forty-eight hours. 

Fermentation Tube. — Acidified, no gas. 

Indol. — Produced by some colonies. 

Pathogenicity. — Pathogenic for rabbits and guinea pigs. 

Chromogenesis. — Pyocyanin and a yellowish-green pigment. 

20. BACTERIUM OXYGENES, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
First isolated from intestinal contents by Ford. 

Morphology. — Bacteria measuring 0.5 by 2.0-3.0 microns. 

Motility. — Non-motile. 

Spores. — Not formed. , 

Agar Slant. — Thick white glistening growth, limited to line of 
inoculation. 

Agar Colonies. — Deep colonies small, brown and regular; super- 
ficial colonies 'large, round, translucent, spreading over the 
surface of the agar and assuming a bluish look. 

Broth. — Turbidity, no scum. 

Gelatine Stab. — Growth along line of inoculation, no liquefaction. 

Gelatine Colonies. — Irregular brownish colonies of various sizes 
and shapes, usually round or oval, not characteristic. 

Potato. — Very abundant yellowish-white or yellowish-brown 
growth, rapidly covering cut surface of potato. 

Fermentation Tube: Dextrose Broth, — Abundant growth in bulb 
with production of a turbidity and sediment. Reaction alka- 
line. No growth in closed arm. 

Saccharose and Lactose not fermented. 

Blood Serum. — Abundant white growth without liquefaction. 

Nitrates. — Not reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — Intense acid-production. Coagulation of the milk 
to a dense hard mass. No liquefaction of the casein, 

21. BACTERIUM BIENSTOCKII, Schroter, 1886. 

Literature and Synonyms. — Bacillus aus Feces, No. iii, Bienstock. 
Bienstock, Ueber die Bakterien der Feces, Zeitschrift fur klin. 
Med., Bd. VIII, Heft 1. 
Bacterium Bienstockii, Schroter. 

Schroter, 1886, Pike Schlesien, p. 163. 



228 EXAMINATION OF TEE FECES. 

Bacillus coprogenes parvus, Bienstock. Fliigge, 188 6, Die 
Mikroorganismen, 2d edition, p. 269; 1896, 3d edition, 
Vol. II, p. 423. 
Bacterium Bienstockii, Schroter. Migula, 1900, System der 

Bakterien, p. 393. 
Bacterium Bienstockii, Schroter. Chester, 1901, Manual of 
Determinative Bacteriology, p. 144. 

First obtained by Bienstock from human feces. 

Morphology. — Very short fine bacteria measuring 0.5 by 0.75 
microns, in stained preparations barely to be distinguished 
from micrococci. 

Motility. — Non-motile. 

Spores. — Not formed. 

Agar Slant. — Growth very slow; after forty-eight to seventy-two 
hours only a faint film produced on agar. 

Agar Colonies. — Small, fine, brown, non-spreading colonies. 

Broth, — Turbidity, no scum. 

Gelatine Stab. — Slow growth along line of inoculation. No lique- 
faction. 

Gelatine Colonies. — Small, fine regular pale brown colonies. 

Potato. — Hardly perceptible, grayish-white growth. 

Fermentation Tube: Dextrose Broth, — Growth in bulb, where 
faint turbidity is produced. Reaction alkaline. No growth 
in closed arm. 

Saccharose and Lactose not fermented. 

Blood Serum. — Faint white film, no liquefaction. 

Nitrates. — Not reduced to nitrites. 

Indol, — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — Acid-production, slow coagulation, eventual pro- 
duction of a dense firm mass. No liquefaction of the casein. 

22. BACILLUS OXYPHILUS, Ford, 1903. , 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
Isolated from intestinal contents by Ford. 
Morphology. — Bacilli measuring 0.75 by 2.0 microns. 
Motility. — Actively motile. 
Spores. — Not formed. 
Agar Slant. — Abundant thick white growth. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 229 

Agar Colonies. — Deep colonies round, regular and grayish; super- 
ficial colonies usually have opaque white centers and slightly 
radiating branches. 

Broth. — Turbidity and rarely a slight scum. 

Gelatine Stab. — Growth along line of inoculation. No liquefac- 
tion. 

Gelatine Colonies. — Irregular, round or oval colonies, presenting 
"broken glass" appearance. 

Potato. — Luxuriant brownish growth. 

Fermentation Tube: Dextrose Broth. —Growth in open bulb with 
the production of turbidity and sediment. Reaction acid. 
Growth in closed arm. Reaction acid. No gas. 
Saccharose and Lactose not fermented. 

Blood Serum, — Luxuriant grayish-white growth. No liquefac- 
tion. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — Acid-production and coagulation of the milk 
within twenty-four hours. No peptonization of the casein. 

23. BACTERIUM ACIDOFORMANS, Sternberg, 1892. 

Literature and Synonyms: Bacillus acidoformans. — Sternberg, 
1892, Manual of Bacteriology, p. 499. 

Bad. Acidoformans, Sternberg. — Chester, 1901, Manual of 
Determinative Bacteriology, p. 150. 

Isolated from the liver of a yellow fever cadaver by 
Sternberg. 

Morphology. — Thick stumpy bacilli measuring 0.75 by 1.0-1.5 
microns, often associated in long chains. 

Motility. — Non-motile. 

Spores. — Not formed. 

Agar Slant. — Abundant thick white growth spreading over the 
surface of agar and turning brown in old cultures. 

Agar Colonies. — Deep colonies, minute and brownish; superficial 
colonies large, opaque and circumscribed. 

Broth. — Turbidity, without scum. 

Gelatine Stab. — Growth along line of inoculation. No liquefac- 
tion. 

Gelatine Colonies. — Deep colonies, fine, opaque : superficial, irreg- 
ular, translucent, non-spreading. 



230 EXAMINATION OF THE FECES. 

Potato. — Luxuriant yellowish-white or yellowish-brown growth. 

Fermentation Tube: Dextrose Broth. — Abundant growth in bulb 
with the production of a turbidity and sediment. Reaction 
acid. Abundant growth in closed arm. Reaction acid. No 
gas formed. 

Saccharose and Lactose not fermented. 

Blood Serum. — Heavy white growth without liquefaction. 

Nitrates. — JSot reduced to nitrites. 

Indol. — ISTot produced. 

Fecal Odor. — ~Not produced. 

Litmus Milk. — Acid reaction within twenty-four hours. Coagula- 
tion of the milk to a hard firm mass. No peptonization of the 
casein. 

24. BACTERIUM MINUTISSIMUM, Migula, 1900. 

Literature and Synonyms: Bacillus pyogenes minutissimus, Kruse. 
— Fliigge, Mikroorganisroen, 1896, Bd.- II, p. 447. 
Bacterium m.inuiissimum } Migula, 1900. Migula, 1900, 
System der Bacterien, p. 418. 

Isolated by Kruse from a brain abscess. 

Morphology. — Fine short bacilli measuring y 2 by 1 micron, 
appearing usually as diplo-bacilli which when stained look 
like diplococci. 

Motility. — Non-motile. 

Spores. — !Not formed. 

Agar Slant. — Faint transparent film visible on the surface only in 
twenty-four-hour cultures, after forty-eight hours sinking into 
the depths of the medium and distinguished with difficulty. 

Agar Colonies. — Deep colonies not characteristic ; superficial colo- 
nies pale gray, round or oval, appearing only after forty-eight 
hours. 

Broth. — Slow growth, with the production of a turbidity but no 
scum. 

Gelatine Stab. — Faint slow growth along line of puncture. No 
liquefaction. 

Gelatine Colonies. — Small, round, regular, pale-brown or pale- 
yellow colonies. 

Potato. — Faint, white, glistening growth, developing after several 
days. 

Fermentation Tube: Dextrose Broth, — Faint turbidity in bulb 
with scanty sediment. Reaction acid. Slow growth in closed 
arm. Reaction acid, no gas. 

Saccharose and Lactose not fermented. 



PLATE X. 



FIO. 1. 



FIG. 2. 




FIG. 3. 



fit 



FIG. 4. 



FIG. S. 




Fig. 1 —Threads of mucus from an infant's stool, in streptococcus enteritis. Stained 
according to Weigert-Eseherieh. X 1000. (After Hirseh.) 

Fig. 2 —Blue baeillosis of Eseherieh. Details as in Fig. 1. 

Fig. 3.— Tubercle bacilli from formed stools. Details as in Fig. 1. (Spores also stained red.) 

Fig. 4.— Dysentery bacilli. Smear from a small clump of pus. Stained with dilute 
earbolie fuehsin. X 1000. 

Fig. 5.— Purulent portion of an infant's stool, in a ease of infectious colitis. Details as 
in Fig. l. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 231 

Blood Serum. — Faint white growth. No liquefaction. 
Nitrates — Reduced to nitrites. 
Indol. — Xot produced. 
Fecal Odor. — !N"ot produced. 

Litmus Milk. — Reaction acid. Coagulation of milk after forty- 
eight hours. No peptonization of casein. 

25. BACILLUS COLI, Migula, 1900. 

Literature and Synonyms: Bacterium coli commune. — Escherich, 
1886, Darmbakterein des Sauglings, Stuttgart. 
Neapeler Bacillus. — Emmerich, 1884, Deutsche med. 

AVochenschrift, jSTo. 50. 
Bacillus Neapolitanus.—FTSienkel, 1887, Grundriss der Bak- 

terienkunde. 
Emmerich's Bacillus. — Eisenberg, 1886, Bakteriologische 

Diagnostik. 
Bacillus pyogenes-fcetidus. — Passet, 1885, iEtiologie eiterigen 

Phlegmon des Menschen, Berlin. 
Bacillus coli. (Escherich.) — Migula, 1900, System der Bak- 

terien, p. 731. 
Bacillus coli communis verus. — Durham, 1900-1901, Journal 

of Experimental Medicine, Vol. V, p. 353. 
Bacillus coli (Escliericli). — Chester, 1901, Manual of Deter- 
minative Bacteriology, p. 205. 

Eirst isolated case by Escherich from the intestinal con- 
tents of infants. 
Morphology. — Short stumpy bacilli measuring 0.5 by 1.0-2.0 
microns. .Occurs usually in single elements, but frequently 
in pairs and short or long chains. When unstained the long 
chains are seen to be made up of 15 to 20 separate bacilli 
linked together. May appear as a diplobacillus which when 
stained looks like a diplococcus. The diplococcoid forms are 
common in young cultures, or, as Adami has pointed out, are 
frequently seen in attenuated cultures from the tissues or 
from the gall bladder. 
Motility. — Bacillus coli always possesses a well-defined motility 
which, while not especially active, is always sufficient to dif- 
ferentiate it from any bacteria. In the 200 cultures of this 
bacillus which were obtained at various intervals, unques- 
tioned motility was demonstrated in every culture. The 
motility is usually less than that of Bacillus typhosus or that 



232 EXAMINATION OF THE FECES. 

of Ps. aeruginosa (Bacillus pyocyaneus), but occasionally 
cultures are encountered where trie bacilli move across the 
field with the velocity of a cholera vibrio. Usually a moderate 
motility. 

Spores. — At no time observed. The diplococcoid form is consid- 
ered by Adami to represent an attempt on the part of the 
bacillus, when grown under unfavorable conditions, to assume 
a more resistant state, but one distinct from spore formation. 

Agar Slant.- — Glistening white or yellowish white growth extend- 
ing rapidly along the line of inoculation, spreading and slop- 
ing to the bottom of the tube, where it develops luxuriantly. 
In old cultures the growth becomes dirty brown, especially 
after drying. Attenuated forms grow as a faint white film on 
the surface of agar. 

Agar Colonies. — Deep colonies, round or oval, regular, sharply cut 
edges, slightly brown in color, nail-form growth often seen ; 
superficial colonies are slightly opaque, brownish, either cir- 
cumscribed or spreading over the surface of the agar and 
assuming diverse forms, sometimes occupying the whole 
plate. 

Broth. — Turbidity and heavy sediment settling to the bottom of 
the tube. Slight filmy scum on the surface sticking to the 
sides of the tube, easily broken up and sinking to the bottom. 
Slight movements, such as handling the broth tube when 
transferring it from one place to another, are sufficient to dis- 
lodge the film. At no time is a scum like that of Ps. aerugi- 
nosa (Bacillus pyocyaneus) with its firm glistening surface or 
that of Bacillus subtilis with its hard leathery look, formed 
by Bacillus coli. 

Gelatine Stab. — Abundant growth along line of inoculation and 
spreading over the surface of the gelatine. No liquefaction. 

Gelatine Colonies. — Deep colonies regular, round or oval, brown- 
ish in color; superficial colonies, opaque, brownish, slightly 
spreading. 

Potato. — Growth varies from faint white glistening barely per- 
ceptible film to an abundant yellowish-brown or even reddish- 
brown mass covering the entire cut surface of the potato. 

The variations in the growth depend more on the nature 
and composition of the potato than upon any variations in the 
bacillus itself, as a number of potato tubes inoculated with the 
same culture will show every conceivable gradation in extent 
and character of growth. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 233 

Fermentation Tube: Dextrose Broth. — Abundant growth in bulb 
with, the production of a turbidity and heavy sediment. 
Rarely, a faint film on the surface. Reaction in bulb acid. 
Abundant growth in closed arm with rapid evolution of gas, 
Reaction in closed arm acid. 

The amount of gas from the dextrose broth varies con- 
siderably in quantity, this quantity depending somewhat on 
the temperature at which the growth takes place, and some- 
what upon the character of the culture itself. The first evolu- 
tion of gas is deceptive, as the fermentation tubes when kept 
for a number of days allow approximately the same quantity 
of gas to collect. 

Saccharose not broken up to either acid or gas. 
Lactose split up with the production of acid and gas. 
The quantity of gas from lactose varies considerably, but if 
the lactose tubes be observed 'for some time the amount of 
gas in the different tubes will be found to reach nearly the 
same level. 

Blood Serum. — Abundant white growth over the surface. No 
liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Usually produced abundantly. The amount is greater 
in old cultures and also in cultures isolated from the lower 
portion of the intestinal tract. At times cultures from the 
stomach give positive indol reactions. Again, cultures of 
organisms which are undoubtedly Bacillus coli fail to pro- 
duce indol. 

Fecal Odor. — Usually produced. ~Not to be regarded as necessary 
for the identification of Bacillus coli, as many cultures fail to 
exhibit it. 

Litmus Milk. — Abundant acidity invariably produced within 
forty-eight hours. Amount of acid constantly increasing, 
milk usually coagulated on the second day. When the coag- 
ulation of milk takes place early, the coagulation is dense and 
firm, but white or pink in color. The amount of acid con- 
stantly increases, and the coagulum assumes a pink color 
which is increased in the presence of oxygen. Shaking the 
tube and breaking up the coagulum produces a deep pink. 
In other cases an acidity is produced early, but the coagula- 
tion is delayed for some days, sometimes for a period of three 
weeks. Coagulation always eventually takes place even 
though delaved for some time. 



231 EXAMINATION OF THE FECES. 

Frequently the transfer of the milk. tubes from a lower 
to a higher temperature, as from that of the room to that of 
the thermostat, will induce coagulation in specimens in 
which the coagulation has failed to appear. Heating in the 
gas flame also throws down the casein. The time at which 
coagulation ensues depends somewhat on the quality of the 
milk used, as freshly inoculated tubes will occasionally reveal 
an immediate coagulation with the same bacillus which orig- 
inally failed to coagulate for days. In two instances, cultures 
were encountered which coagulated milk within eighteen 
hours, the coagulum remaining white and colorless. In all 
other respects this organism corresponded to a typical Bacillus 
coll. Booker, 1889, has also referred to this variety. 

Under all circumstances the 'production of acidity and 
the coagulation of milk must he regarded as essential to the 
diagnosis of Bacillus coli. No production of alkali at any 
period. No peptonization of the casern. 
Occurrence and Distribution. — Found in 27 different cases, i. e., 
in over 50 per cent, of the cases examined by Ford, and thus 
more frequent than Bacillus communior of Durham. 

Isolated from the rectum alone in five cases, from the 
cecum alone in four cases, from the duodenum alone in two 
cases and from the stomach alone in one case. 

Isolated from two portions of the intestinal tract in ten 
cases ; from cecum and rectum in six cases, rectum and duo- 
denum once, rectum and stomach once, and stomach and 
duodenum twice. 

It was obtained from three portions of the intestinal 
tract in four cases ; from stomach, duodenum and cecum 
twice; from stomach, duodenum and rectum once, and from 
duodenum, cecum and rectum once. In one case found in 
the stomach, duodenum, cecum and rectum. 

It is thus seen to be one of the most common inhabitants 
of the intestinal tract, appearing in all its regions, but espe- 
cially favoring a location in the cecum and rectum, although 
wandering frequently to the duodenum and stomach, where 
it grows abundantly and where its cultures produce charac- 
teristic reactions on culture media. 

26. BACILLUS COMMUNIOR, Ford, 1903. 

Literature and Synonym: Bacillus coli communior. — Durham, 
1900-1901, Journal of Experimental Medicine, Vol. V, p. 



BACTERIOLOGICAL EXAMINATION OF TEE FECES. 235 

353. Ford, W. W., 1900, Classification Intestinal Bacteria, 
Journal of Medical Research, Vol. I, p. 211. 

As already stated, Durham has called attention to the 
fact that the variety of Bacillus coli, which was originally 
described by Escherich, is not endowed with the property of 
fermenting saccharose, and that this variety is Dot as common 
in the intestinal tract as the organism fermenting the three 
sugars. Our observations on the intestinal flora substantiate 
Durham's conclusions in their main details. There are two 
great groups of Bacillus coli to be separated by their capacity 
of splitting up saccharose, as has already been mentioned, to 
one of which the name, Bacillus coli, Escliericli, is exactly 
applicable, while for the other the name Bacillus communior. 
may be utilized, reserving as a synonym the term originally 
proposed by Durham, Bacillus coli communior. 

In regard to the frequency with which these two micro- 
organisms are present in the intestinal contents, Ford was 
unable to confirm Durham's work. The Bacillus coli ferment- 
ing saccharose is somewhat less common than the true Bacil- 
lus coli of Escherich, and thus the name of Bacillus com- 
munior may not be interpreted numerically, although it be 
retained as a specific name. 

The cultures of Bacillus communior agree in all im- 
portant respects with the pure type of this species, in mor- 
phology, motility, none-liquefaction, acid-production and in 
their reactions with dextrose broth in the fermentation tube. 
Saccharose is fermented, however, with the production of 
acidity and much gas. 
Occurrence and Distribution. — Obtained by Eord in 26 of 50 
examined, as compared with 27 for the type ; and in 44 por- 
tions of the intestinal tract, as compared with 47 for the type. 

Found in one portion of intestinal tract alone in 14 cases, 
in eight of which it was isolated from the rectum, in two 
from the cecum, in one from the duodenum, and in three 
from the stomach. In seven cases it appeared in two regions 
in the combinations, rectum and cecum three times, rectum 
and duodenum once, cecum and duodenum once, and duode- 
num and cecum twice. 

In four cases it was obtained from three portions; rec- 
tum, cecum and stomach twice, cecum, stomach and duode- 
num twice. In one case it was obtained from all the differ- 
ent regions of the intestine examined, appearing concurrently 



286 EXAMINATION OF THE FECES. 

in the stomach, duodenum, cecum and rectum. It thus is 
present in all portions of the bowel, especially towards the 
lower end, but is able to occupy the duodenum and stomach 
as well. 

27. BACTERIUM AEROGENES, Migula, 1900. 

Literature and Synonyms: Bacterium lactis cerogenes. — Escherich, 
1886, Die Darmbacterien des Sauglings, Stuttgart, p. 57. 
Bacterium aceticum. — Baginsky, 1888, Zeitschrift f. phys. 

Chemie, 12, p. 434. 
Bacillus cerogenes. — Kruse, 1896, Eliigge, Die Mikroorgan- 

ismen, p. 340. 
Bacterium cerogenes. — (Escherich.) Migaila. Migula, 1900 / 

System der Bakterien, p. 396. 
Bacterium cerogenes. — Escherich. Chester, 1901, Manual of 
Determinative Bacteriology, p. 128. 

First isolated by Escherich from the intestinal contents 
of infants. 

Morphology. — Short stubby bacteria usually measuring 0.75 by 
1.0 microns. When stained these forms resemble large cocci. 
When unstained are seen to be short bacteria. Longer bac- 
teria of the same diameter as the typical forms are frequently 
met with, their length approximating 2.0 microns, the diam- 
eter, however, being identical with that of the short stubby 
forms. Milk cultures show the development of a capsule, 
the presence of which contributes to the peculiar thick form 
of the micro-organism. 

The morphology of Bacterium cerogenes is always char- 
acteristic, and is of prime importance in its identification. 

Motility. — Motility cannot be demonstrated at any time either in 
agar and broth cultures, or in old cultures. 

Spores. — Xot formed. 

Agar Slant. — Abundant thick white glistening growth, usually 
heaped up at the edges and along the line of inoculation. It 
often spreads over the surface and slopes to the bottom of 
the tube. It rarely penetrates deeply beneath the surface of 
the agar, and it recovers its typical appearance after several 
inoculations. 

Agar Colonies. — Deep colonies, round and regular ; superficial 
colonies, thick, opaque, raised slightly from the surface and 
circumscribed in outline. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 237 

Broth. — Great turbidity, abundant sediment and usual produc- 
tion of scum. 

Gelatine. — Thick growth along line of inoculation and spreading 
over the surface of the gelatine. No liquefaction. 

Gelatine Colonies. — Deep colonies, round, regular, grayish brown; 
superficial colonies, thick, opaque, porcelain white. 

Potato. — Thick, yellowish-white or yellowish-brown growth with 
peculiar wart-like elevations along the edges and upon the 
surface. 

Fermentation Tube: Dextrose Broth. — Turbidity and sediment in 
bulb. Reaction acid in bulb. Abundant growth in closed 
arm with the production of an acid reaction and much gas. 
Saccharose and Lactose also fermented with the produc- 
tion of gas and acid. 

Blood Serum. — Abundant glistening white growth. No liquefac- 
tion. 

Nitrates. — Reduced to nitrites. 

Indol. — Usually not produced. Occasionally typical cultures of 
Bacterium cerogenes give characteristic and positive reactions 
for indol. 

Litmus Milk. — Acidity produced within eighteen hours. Coagu- 
lation of the milk usually within the first twenty-four hours, 
the coagulum being a pale pink in color. The color deepens 
with the production of acidity and by the free access of oxy- 
gen to the coagulum. The coagulation may be delayed fifteen 
or twenty days, but always eventually develops. It may fre- 
quently be hastened by rapid changes of temperature. Bac- 
teria which, with some specimens of milk coagulate only at a 
late date, will coagulate other samples within forty-eight 
hours. Occasionally a perfectly white coagulum is produced 
in the first day, only a faint acidity developing, analogous to 
certain cultures of Bacillus coli. No peptonization of casein. 
Production of acidity and coagulation of milk essential 
in the identification of Bacterium cerogenes. 

Occurrence and Distribution. — Isolated by Ford from 31 cases, 
thus being the most frequent micro-organism in the intestinal 
tract. In the 31 cases it was found in 56 different regions. 

In 12 cases it was obtained from one region of the bowel 
alone, from the stomach in five cases, from the duodenum in 
three cases, from the cecum in three and from the rectum in 
one case. It was found in combination in two regions in 



238 EXAMINATION OF THE FECES. 

15 cases; in stomach and duodenum four times, in stomach 
and cecum four times, in stomach and rectum twice, in duo- 
denum and cecum four times, and in the cecum and rectum 
once. 

Three times it was seen in three different portions of 
the intestinal tract, stomach, duodenum and cecum, once; 
stomach, cecum and rectum, once ; and in the duodenum, 
cecum and rectum, once. It was obtained from all four 
regions of the intestines examined in one case, stomach, duo- 
denum, cecum and rectum. 

The Bacterium cerogenes thus enjoys a very wide distri- 
bution in the intestinal contents, being most frequently seen 
in the stomach and duodenum, but also being carried down 
to the cecum and rectum, where it dwells side by side with 
Bacillus coli. 

28. BACTERIUM DUODENALE, Ford, 1903. 

Besides the typical Bacterium cerogenes, capable of fer- 
menting three sugars, a micro-organism corresponding in its 
main cultural features to Bacterium cerogenes, but differing 
in regard to its inability to ferment saccharose, is a common 
inhabitant of the intestines. To this organism the name Bac- 
terium duodenale may be given, indicating its more frequent 
habitat, the duodenum. 

In morphology, lack of motility, non-liquefaction and 
reactions with the fermentation tube, it agrees with Bacterium 
cerogenes. 

It was isolated by Ford from 28 cases and from 45 dif- 
ferent regions. It was found in one region alone in 18 cases, 
in the stomach in five, in the duodenum in three, in the 
cecum in six and in the rectum in four cases ; in stomach and 
duodenum once; in stomach and rectum once and" in the 
cecum and rectum twice. In Hve cases it was seen in three 
regions, stomach, duodenum and cecum three times, and 
stomach, duodenum and rectum twice. In one case it was 
found in stomach, duodenum, cecum and rectum. 

The Bacterium duodenale is thus most frequently found 
in the stomach and duodenum, but may be carried down to 
the cecum aud rectum. Like Bacterium cerogenes it prefers, 
however, a location in the upper portion of the intestines. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 239 

29. BACILLUS GASTEICUS, Ford 1902. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
First obtained from the intestinal contents by Ford. 

Morphology. — Small bacilli measuring 0.5 by 2-3.0 microns, 
appearing as single elements or rarely in short chains. 

Motility. — Active motility ; bacilli move rapidly from one portion 
of the field to another. 

Spores. — Not formed. 

Agar Slant. — Glistening white or yellowish white abundant 
growth, usually limited to line of inoculation. 

Agar Colonies. — Deep colonies, round and regular • superficial col- 
onies, thick, opaque, non-spreading. 

Broth. — Turbidity, no scum. 

Gelatine Stab. — Rapid and complete liquefaction from surface 
downward, the fluid gelatine forming a thick layer aboTe the 
solid within twenty-four hours. 

Gelatine Colonies. — Deep colonies, round and regular; superficial 
colonies, of various dimensions, opaque with dark centers and 
slightly spreading periphery. 

Potato. — Luxuriant brownish or brownish-red growth. 

Fermentation Tube: Dextrose Broth. — Abundant growth in open 
bulb with the production of turbidity and a heavy sediment. 
Reaction acid in bulb. Growth in closed arm with the evolu- 
tion of gas and an acid reaction. 

Saccharose and Lactose also fermented with the produc- 
tion of acidity and gas. 

Blood Serum. — Abundant dark-yellow or greenish-brown growth. 
No liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Usually produced. 

Fecal Odor. — Usually produced. 

Litmus Milk. — Rapid production of acidity, coagulation of the 
milk, coagulum dense and firm. No peptonization of the 
casein. 

30. BACILLUS SUBGASTRICUS, Ford, 1902. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 

An organism differing from Bacillus gastricus in not 
fermenting saccharose, but in agreeing with it in its general 
cultural features was isolated from two cases. 



240 EXAMINATION OF THE FECES. 

To this bacillus the name Bacillus subgasiricus may be 
given. It was obtained from the stomach and duodenum in 
one case, and from the duodenum and cecum in another. 

31. BACTERIUM LIQUEFACIENS (Eisenberg, 1892), Ford, 1902. 

Literature and Synonym: Bacillus liquefaciens. — Eisenberg, 
1892, Bakt. Diagnostik, p. 13. 

Originally obtained by Eisenberg from feces, later from 
water. 
Morphology. — Broad, thick bacteria, measuring 0.75 by 2.0 in 
dimensions. 

Motility. — Non-motile. 

Spores. — ~Not formed. 

Agar Slant. — White glistening abundant growth, thick and 
heaped up along line of inoculation, but not spreading or 
sloping. 

Agar Colonies. — Deep colonies, round and regular; superficial col- 
onies, large, round, opaque, circumscribed, varying greatly in 
size. 

Broth. — Turbidity, no scum. 

Gelatine Stab. — Slow growth along line of inoculation; cone-like 
liquefaction appearing on the fifth or sixth day and progress- 
ing slowly ; no surface growth. 

Gelatine Colonies. — Deep colonies, round and regular; superficial 
colonies, slightly spreading, grayish, looking like broken 
glass when thickly sewn. 

Potato. — Luxuriant dirty-brown growth. 

Fermentation Tube: Dextrose Broth. — Abundant growth in bulb 
with turbidity and sediment. Reaction in bulb acid. Growth 
in closed arm with the evolution of gas and the production of 
an acid reaction. 

Saccharose and Lactose also fermented to acid and gas. 

Blood Serum. — Abundant yellowish growth. No liquefaction. 

Nitrates. — Reduced to nitrites. 

Indo I. — Abundant. 

Fecal Odor. — Frequently present. 

Litmus Milk. — Acidification and coagulation of the milk within 
forty-eight hours. No peptonization of the casein. 

32. BACTERIUM SUBLIQUEFACIENS, Ford, 1902. 

Organisms agreeing in their main cultural features with 
the preceding, but failing to ferment saccharose, are more 



BACTERIOLOGICAL EXAMINATION 7 OF TEE FECES. 241 

frequently present in the intestines than are the typical form. 
To them the name Bacterium subliquefaciens may be given. 
They were met with in three cases, once in the duodenum, 
once in the cecum, and once in combination in the stomach 
and rectum. 

33. BACILLUS CLOACA, Jordan, 1890. 

Literature. — Jordan, 1890, Report of the State Board of Health 
of Massachusetts, Part XI, p. 836. 
Migula, 1900, System der Bakterien, p. 722. 
Chester, 1901, Manual of Determinative Bacteriology, p.. 232. 
First obtained by Jordan from sewage. 

Morphology. — Short thin bacilli, measuring 0.5-1.0 by 1-2.0 
microns. 

Motility. — Actively motile. 

Spores. — Xot formed. 

Agar Slant. — Porcelain-white glistening growth, spreading over 
the surface of the agar. 

Agar Colonies. — Deep colonies, round and regular; surface colo- 
nies thick, opaque, round, or with opaque white centers with 
thin outlying periphery. 

Broth. — Turbidity and frequently a thin scum. 

Gelatine Stab. — Complete, usually rapid liquefaction, fluid gela- 
tine lying above the solid medium. In certain cultures the 
liquefaction is very slow. 

Gelatine Colonies. — Deep colonies, round, regular, yellowish; 
superficial colonies, thin, bluish, translucent. 

Potato. — Luxuriant dull-white or yellowish-white growth. 

Fermentation Tube: Dextrose Broth. — Sediment and turbidity in 
bulb; reaction acid. Abundant growth in closed arm. Evo- 
lution of gas and an acid reaction. 

Saccharose and Lactose alike fermented to acid and gas. 

Blood Serum. — Abundant growth, liquefaction slow, but complete 
after ten to twelve days. 

Nitrates. — Reduced to nitrites. 

Indol. — Usually produced. 

Fecal Odor. — Usually present. 

Litmus Milk. — Slow development of acidity and eventual coagula- 
tion of the milk. Gradual peptonization of the casein. 

16 



242 EXAMINATION OF TEE FECES. 

34. BACILLUS SUBCLOAOE, Ford, 1902. 

Organisms corresponding to Bacillus cloacce in all 
respects except in their fermentation of saccharose may con- 
veniently be grouped together under the name Bacillus sub- 
cloacae. They were isolated from the intestinal contents in five 
cases, from stomach, duodenum, cecum and rectum separately 
once, and from, the duodenum, cecum and rectum together 
once. 

35. BACILLUS ILIACUS, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 

Morphology. — Very large bacilli measuring 0.75 by 3-4.0 microns, 
appearing invariably as single elements. 

Motility. — Actively motile, the bacilli shooting rapidly from one- 
portion of the field to another. 

Spores. — Not formed. 

Agar Slant. — White glistening growth spreading over the whole 
surface of the agar. 

Agar Colonies. — Deep colonies, round and regular; superficial 
colonies, opaque, spreading rapidly over the surface, with thick 
opaque centers and thin translucent margins. 

Broth. — Turbidity and thick scum. 

Gelatine Stab. — Rapid growth along line of inoculation with com- 
plete liquefaction of the gelatine from the surface down- 
ward. 

Gelatine Colonies. — Deep colonies, regular, slightly brown ; super- 
ficial colonies, large, translucent and spreading. 

Potato. — Abundant yellowish-brown growth. 

Fermentation Tube : Dextrose Broth. — Rapid growth in bulb with 
the production of a scum and turbidity. Reaction acid. 
Growth in closed arm with the evolution of gas and the for- 
mation of acid. 

Saccharose also fermented with the production of gas and 

acidity. 
Lactose not broken up to either acid or acid and gas. 

Blood Serum. — Abundant dull-brown growth with a rapid and 
complete liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 243 

Litmus Mill'. — Rapid acidification and coagulation with an early 
peptonization of the casein and a reduction of the litmus. 

36. BACILLUS CHYLOGENES, Ford, 1903. 

Literature. — Ford, W. W., .1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
First obtained from intestinal contents by Ford. 
Morphology. — Small, fine bacilli, measuring about 0.5 by 1.0 
microns, appearing as diplo-bacilli which, when stained, look 
like diplococci. 
Motility. — Actively motile. 
Spores. — Xot formed. 
Agar Slant. — Pale, almost transparent film, almost invisible even 

after the la23se of forty-eight hours. 
Agar Colonies. — Deep colonies, very fine pale brown; superficial 
colonies, oblong or nail-shaped, very small, pale brown in 
color; growth very slow. 
Broth. — Marked turbidity after forty-eight to seventy-two hours. 

ISTo scum. 
Gelatine Stab. — Slow growth along line of inoculation, with begin- 
ning liquefaction, which is completed only after 6 to 8 days. 
Gelatine Colonies. — Small, round, regular, non-characteristic, deep 

and superficial colonies. 
Potato. — Growth varies from a scanty white to a pale yellow 

brown appearing after forty-eight hours. 
Fermentation Tube: Dextrose Broth. — Turbidity in bulb with a 
scanty sediment. Reaction acid in bulb. Slow growth in 
closed arm. Reaction in arm acid. No gas. 

Saccharose and Lactose not fermented to acid alone nor 
to acid and gas. 
Blood Serum. — Abundant pale white growth developing very 

slowly, but not producing any liquefaction. 
Nitrates. — Xo reduction to nitrites. 
Indol. — Xot produced. 
Fecal Odor. — Xot produced. 

Litmus Milk. — Within forty-eight hours production of a slight 
acidity which constantly increases till the milk is coagulated, 
and a pink color is eventually produced. No peptonization of 
casein. 



244 EXAMINATION OF TEE FECES. 

37. BACTERIUM CHYMOGENES, Ford, 1903. 

Literature. — Ford, W. W., 1901, Classification of , Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
First obtained by Ford from intestinal contents. 

Morphology. — Bacteria measuring 0.5 by 2.0 microns in dimen- 
sions. 

Motility. — Non-motile. 

Spores. — Not formed. 

Agar Slant. — Abundant white glistening growth, heaped up above 
line of inoculation. 

Agar Colonies. — Deep colonies, round and regular ; surface colo- 
nies, large, opaque, round, circumscribed, varying greatly in 
size. 

Broth. — Turbidity, no scum. 

Gelatine Stab. — Slow growth along line of inoculation ; slow lique- 
faction complete after seven to eight days. 

Gelatine Colonies. — Deep colonies, round, regular; superficial col- 
onies, large, regular, refractile, non-characteristic. 

Potato. — Luxuriant dirty brown growth. 

Fermentation Tube: Dextrose Broth. — Turbidity and sediment in 
bulb. Reaction in bulb acid. Growth in closed arm with the 
production of acidity, but no gas. 

Saccharose and Lactose not fermented, to either acid or 
acid and gas. 

Blood Serum. — Abundant growth, yellowish-white. No liquefac- 
tion. 

Nitrates. — Not reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — Acidification and coagulation within forty-eight 
hours. No digestion of the casein. 

38. BACILLUS LEPORIS, Migula, 1900. 

Literature and Synonyms: Bacillus leporis lethalis. — Sternberg, 
1890, Text-book of Bacteriology, p. 478. 
Bacillus leporis (Sternberg) Migula. — Migula, 1900, System 

der Bakterien, p. 651. 
Bacillus leporis (Sternberg). — Chester, 1901, Manual of 
Determinative Bacteriology, p. 243. 

Isolated first by Gibier and later by Sternberg from the 
contents of the intestine in yellow fever. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 245 

Morphology. — Very long, thin bacilli measuring 0.5 by 4-6.0 
microns, always made up of long single elements and never 
appearing in chains. 

Motility. — Bacilli are very actively motile, shooting rapidly from 
one portion of the field to another with the velocity of a cul- 
ture of Proteus aeruginosa (Bacillus pyocyaneus). 

Spores. — ~Not formed. 

Agar Slant. — Abundant white glistening growth in young cultures, 
but rapidly drying and turning brown in old cultures. 

Agar Colonies. — Deep colonies, round and uniform; surface colo- 
nies, round, slightly spreading, with serrated edges, grayish 
in color. 

Broth. — Turbidity, no scum. 

Gelatine Stab. — Abundant growth, rapid and complete liquefac- 
tion, beginning at the surface and proceeding downwards. 

Gelatine Colonies. — Deep colonies, round, translucent, light-yel- 
low; surface colonies, transparent, spreading, with broken 
glass appearance. 

Potato. — Luxuriant yellowish-brown growth within three to four 
days. 

Fermentation' Tube: Dextrose Broth. — Turbidity and sediment in 
bulb. Acid reaction. Growth in closed arm with the produc- 
tion of an acid reaction but no gas. 

Saccharose and Lactose alike fermented to acid but no 
gas. 

Blood Serum. — Abundant growth in twenty-four hours. Rapid 
and complete liquefaction of the blood serum. 

Nitrates. — Reduced to nitrites. 

Indol. — Usually produced. 

Fecal Odor. — Rarely produced. 

Litmus Milk. — Rapid acidification and coagulation of the milk 
No peptonization of the casein or reduction of the litmus. 

39. BACILLUS DUBIUS, Kruse, 1896. 

Literature. — Bleisch, 1893, Zeitschrift ftir Hygiene, Vol. XIII, 
p. 31. Fliigge, 1896, Die Mikroorganismen. Chester, 1901, 
Manual of Determinative Bacteriology, p. 237. 
First isolated from feces by Bleisch. 

Morphology. — Short, thin bacilli measuring 0.75 by 2.0 microns, 
sometimes appearing in pairs. 

Motility. — Actively motile. 



246 EXAMINATION OF THE FECES. 

Spores. — Not formed. 

Agar Slant. — Abundant glistening, yellowish growth, turning 
brown in old cultures. 

Agar Colonies. — Deep colonies, round, regular, opaque; superficial 
colonies, grayish, spreading over surface, corrugated or skein- 
like in appearance. 

Broth.- — Turbid, no scum. 

Gelatine Stab. — Abundant growth along line of inoculation. Rapid 
and complete liquefaction, usually within three days. 

Gelatine Colonies. — Deep colonies, round and regular; superficial 
colonies, fine, irregular, slightly spreading, grayish brown. 

Potato. — Abundant yellowish-brown glistening mass. 

Fermentation Tube: Dextrose Broth. — Abundant growth in bulb 
with a heavy sediment, Reaction in bulb acid. Abundant 
growth in closed arm with an acid reaction but no gas. 

Saccharose and Lactose not fermented to acid or gas. 

Blood Serum. — Yellowish growth and a slow but complete lique- 
faction. 

Nitrates. — Reduced to nitrites. 

Indol. — Produced in small quantities. 

Fecal Odor. — Produced in small amount. 

Litmus Milk. — Acidification and coagulation within forty-eight 
hours. Slow and complete peptonization of the casein with a 
reduction of the litmus. 

40. * BACILLUS JEJUNALIS, Ford, 1902. 

Literature. — Ford, W. W., 1901, Classification of Intestinal 
Bacteria, Journal of Medical Research, Vol. I, p. 211. 
First isolated from intestinal contents by Ford. 

Morphology. — Short bacilli measuring 0.5 by 2.0 microns, appear- 
ing as single elements or as long chains. 

Motility. — Actively motile. 

Spores. — Not formed. 

Agar Slant. — Abundant thick white growth within forty-eight 
hours. 

Agar Colonies. — Deep colonies, round, regular, dark brown ; 
superficial colonies, may be large, translucent, pale blue, or 
spreading / with opaque centers and filmy transparent mar- 
gins, assuming star shapes or bizarre shapes. 

Broth. — Turbidity but no scum. 

Gelatine Stab. — Abundant growth. Rapid and complete liquefac- 
tion. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 217 

Gelatine Colonies. — Deep colonies, fine, brown, regular ; superficial 

colonies are large, irregular, slightly spreading, dark brown 

in color. 
Potato. — Luxuriant glistening white growth. 
Fermentation Tube: Dextrose Broth. — Turbidity and sediment in 

bulb. Reaction in bulb acid. Abundant growth in closed arm 

with the production of acidity but no gas. 

Saccharose and Lactose not fermented to acid or gas. 
Blood Serum. — Slow white growth, becoming very luxuriant after 

eight to ten days, and causing a complete liquefaction of the 

medium. 
Nitrates. — Reduced to nitrites. 
Indol. — !Not produced. 
Fecal Odor. — !Not produced. 
Litmus Milk. — Acidification and coagulation within forty-eight 

hours. Slow peptonization of 'the casein but no reduction of 

the litmus. 

41. PSEUDOMONAS .ERUGINOSA (Schroter, 1872), Migula, 1900. 

Literature and Synonyms. — Bacterium, ceruginosum. Schroter, 
1872, Ueber einige durch Bakterien gebildete Pigmente, 
(John's Beitrage zur Biologie, Bd. I, p. 126. 

Bacillus ceruginosus. Schroter, 1872. Schroter, 1886, Kryptog. 
Enc. Flora von Schlesien, Bd. Ill, p. 157. 

Bacillus pyocyaneus. Gessard, 1882, De la pyocyanine et de son 
microbe, These de Paris. 

Pseudomonas pyocyanea. Migula, 1896, Die ^atiirlichen Pflan- 
zenfamilien. 

Pseudomonas pyocyanea (Gessard) Migula. Chester, 1901, 
Manual of Determinative Bacteriology, p. 321. Migula, 
1896, System der Bakterien, p. 884. 

First accurately described by Gessard in 1882. Pound 
frequently on the surface of the body, in the mouth, 
intestines, and in many pathological conditions. 

Morphology. — Pine bacilli measuring 0.5 by 2.0 microns, appear- 
ing as single elements, pairs and short chains. 

Motility. — Actively motile, bacilli shooting rapidly from one por- 
tion of the field to another. 

Spores. — j^ot formed. 

Agar Slant. — Abundant glistening white growth within twenty- 
four hours, rapidly producing* a bright green pigment which 



248 EXAMINATION OF THE FECES. 

is imparted to the medium. The growth itself rapidly turns 
dark brown. 

Agar Colonies. — Deep colonies, round and regular, yellowish; 
superficial colonies, large, spreading with darker centers and 
translucent edges, assuming various bizarre formations and 
producing a green color in the surrounding agar. 

Broth. — Great turbidity and heavy tenacious scum rapidly 
formed. Bright green fluorescence produced. 

Gelatine Stab. — Abundant growth along line of inoculation and on 
the surface. Rapid liquefaction of the gelatine which assumes 
a bright green color. 

Gelatine Colonies. — Deep colonies, round and regular, yellowish; 
superficial colonies, yellowish or greenish yellow, fringed, 
irregular, producing a skein-like formation. 

Potato. — Luxuriant dirty-brown growth, the potato assuming a 
greenish color. 

Fermentation Tube: Dextrose Broth. — Abundant turbidity with 
the formation of thick scum. Reaction of bulb alkaline. No 
groivth in closed arm. Dextrose broth assumes a bright green 
color. 

Saccharose and Lactose also show a heavy scum and 
assume a bright green color. 

Blood Serum. — Rapid growth, the serum turning bright green and 
rapidly being liquefied. 

Nitrates. — Not reduced to nitrites. 

Indol. — Wot produced. 

Fecal Odor. — Not produced, in its place a characteristic odor of 
trimethylamin. 

Litmus Milk. — Reaction of litmus unchanged; no acid produc- 
tion, no coagulation. Rapid digestion of the casein and reduc- 
tion of the litmus. 

Fluorescence and Chromo genesis. — Greenish. 

Occurrence and Distribution. — Frequently present in the intestinal 
contents. Found in nine cases, being isolated from one por- 
tion of the intestines alone in five cases, four times from the 
rectum and once from the cecum. In one case found in the 
duodenum and rectum. In three cases it was isolated from 
every portion of the intestines, appearing simultaneously in 
stomach, duodenum, cecum and rectum. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 249 

42. PSEUDOMONAS OVALIS (Ravenel, 1896), Chester, 1901. 

Literature and Synonym. — Bacillus fluoresceins — ovalis. Ravenel, 
1896, Memoirs National Academy of Sciences, No. 9. 

Pscudomonas ovalis. Chester, 1901, Manual of Determinative 
Bacteriology, p. 325. 

First obtained from the soil by Ravenel. 

Morphology. — Very fine bacilli measuring 0.5 by 2.0 microns, 
appearing usually as single elements. 

Motility. — Actively motile. Bacilli shoot rapidly from one por- 
tion of the field to another. 

Spores. — Not formed. 

Agar Slant. — Thick, white abundant growth. No pigment pro- 
duction. Green fluorescence produced only in six to eight 
days. 

Agar Colonies. — Deep colonies, fine, colorless ; superficial colonies, 
round, regular, circumscribed, opaque, gradually producing a 
greenish fluorescence. 

Broth. — Scum and turbidity. 

Potato. — Luxuriant dirty brown growth. 

Fermentation Tube: Dextrose Broth. — Turbidity in bulb. Scum 
on surface of broth. Reaction in bulb alkaline. No growth 
in closed arm. Abundant green fluorescence. 

Saccharose and Lactose show a green fluorescence, scum 
on surface, but no fermentation. 

Gelatine Stab. — Abundant growth along line of puncture. No 
liquefaction. 

Gelatine Colonies. — Deep colonies, fine, regular, colorless; super- 
ficial colonies, irregular, with faint prolongations, which 
give a granular appearance like broken glass. 

Blood Serum. — Abundant growth without liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — No preliminary acidity. Alkali production imme- 
diate. No coagulation of the milk. No digestion of the 
casein. No reduction of the litmus. 

Fluorescence. — Green in all fluid cultures and in old agar tubes. 
No chromoffenesis. 



250 EXAMINATION OF THE FECES. 

43. BACTERIUM HAVANIENSE (Sternberg, 1892), Chester, 1901. 

Literature and Synonym: Bacillus Havaniensis. — Sternberg, 1892, 
Manual of Bacteriology, p. 718. (Not Bacillus Havaniensis 
of Migula, 1900.) 
Bacterium Havaniense (Sternberg.) Chester, 1901, Manual of 
Determinative Bacteriology, p. 178. 

First isolated by Sternberg from the intestinal contents 
of yellow fever cadavers. 
Morphology. — Short, fine bacteria measuring 0.5 by 0.75 microns, 
in stained preparations looking like micrococci or diplococci. 
In unstained preparations seen to be true bacteria. 
Motility. — Non-motile. 
Spores. — Not formed. 

Agar Slant. — Bacteria grow rapidly on agar, forming a dull, thick, 
white growth. Occasionally a carmine red growth is pro- 
duced, at the temperature of the body within twenty-four 
hours, but usually the pigment production is delayed for 
forty-eight to seventy-two hours. Pigment is formed at the 
edge of the growth, which after six to eight days is com- 
pletely colored. Cultures freshly isolated from the intestine 
show a much more rapid pigment production. Growth never 
tenacious. No fluorescence. 
Agar Colonies. — Deep colonies, round and regular, colorless; 
superficial colonies may be white, opaque or carmine red, 
with other colonies showing gradations between the two. The 
colonies are usually white with reddish margins. In the same 
plate all the varieties of colonies may be seen. After the 
lapse of forty-eight or seventy-two hours the colonies all 
become carmine red. 
Broth. — Turbidity and heavy scum. No fluorescence. 
Gelatine Stab. — Rapid growth and complete liquefaction. Gela- 
tine turned a brilliant red. 
Gelatine Colonies: Characteristice appearance. — Gelatine is lique- 
fied within twenty-four hours, and assumes a bright red 
color. Floating about in the liquefied gelatine are numerous 
small colonies with dark red centers and lighter peripheries. 
No odor from gelatine plate. 
Potato. — Luxuriant growth, at first white but rapidly becoming a 

dark red. 
Fermentation Tube: Dextrose Broth. — Heavy scum and great tur- 
bidity. Reaction acid. Growth in closed arm. Acid reac- 
tion. No gas. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 251 

Saccharose fermented to acid and gas. 
Lactose not fermented to acid or gas. 
Blood Serum. — Abundant carmine red growth. No liquefaction. 
Nitrates. — Reduced to nitrites. 
Indol. — Not produced. 
Fecal Odor. — Not produced. 

Litmus Milk. — Reaction of milk remains unchanged. No demon- 
strable production of acid or alkali. Coagulation of the milk 
with digestion of the casein and reduction of the litmus. 

44. BACTERIUM LUTESCENS, Migula, 1900. 

Literature and Synonym: Der gelbe Bacillus. — Migula, 1900, 
System der Bakterien, p. 476. Lustig, 1893, Diagnostik der 
Bakterien des Wassers, p. 78. 

First isolated by Lustig from water. 

Morphology. — Short bacteria measuring 0.5 by 0.75 microns, 
appearing like cocci and diplococci in stained preparations. 

Motility. — Non-motile. 

Agar Slant. — Growth slow. Pale yellow at first, later turning to 
a golden yellow. No fluorescence. 

Agar Colonies. — Deep colonies, round, regular and pale yellow; 
superficial colonies, circumscribed, white colonies later becom- 
ing golden yellow. 

Broth. — Turbidity, no scum. No fluorescence. 

Gelatine Stab. — Slow growth. Gradual complete liquefaction. 

Gelatine Colonies— r-Deep colonies, round, circumscribed; super- 
ficial colonies, fine, round, with slight peripheral extensions, 
gradually becoming golden yellow. 

Potato. — Luxuriant golden yellow growth. 

Fermentation Tube: Dextrose Broth. — Turbidity arid sediment in 
bulb. Reaction alkaline. No growth in closed arm. 
Saccharose and Lactose also not fermented. 

Blood Serum. — Abundant yellowish growth; no liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — No preliminary acidity. Alkali production imme- 
diate. No coagulation of the milk. No digestion of the 
casein. 

Chromogenesis , yellow. No fluorescence. 



252 EXAMINATION OF THE FECES. 

45. BACTERIUM ANTHRACOIDES (Hueppe and Wood, 1889), 

Migula, 1900. 

Literature and Synonym: Bacillus anthracoides. — Hueppe and 
Wood, 1889, Berliner klin. Wochen. No. 16. 
Bacterium anthracoides, Migula, 1900, System der Bakterien, 

p. 281. - 
Bacillus anthracoides (Kruse), Chester, 1901, Manual of 
Determinative Bacteriology, p. 191. 

First isolated by Hueppe and Wood from soil and 
water. 

Morphology. — Long, thick, heavy bacteria appearing as single ele- 
ments or in long chains, measuring 1.5 by 2-4.0 microns. The 
individual bacteria show granules at either end, which, when 
stained, form bipolar bodies. 

Spores. — Formed rapidly in all media. 

Motility. — Non-motile. 

Agar Slant. — Dull white, non-glistening growth, drying rapidly 
along upper portions of the agar, and becoming thickly 
wrinkled after six or eight days. 

Agar Colonies. — Deep colonies, small, round, regular and opaque; 
superficial colonies spread over the surface of the agar, assum- 
ing diverse shapes and coalescing, forming a dense felt-work 
which appears gray to the naked eye. 

Broth. — Turbidity and wrinkled scum after forty-eight hours. 

Gelatine Stab. — Rapid and complete liquefaction. 

Gelatine Colonies. — Deep colonies, round and regular; superficial 
colonies, opaque, gray, spreading, irregular, forming a skein- 
like network. Plate rapidly liquefied. 

Potato. — Abundant grayish-white, or rarely, reddish-white, 
growth, never becoming wrinkled. 

Fermentation Tube: Dextrose Broth. — Turbidity in bulb. 
Wrinkled scum. Reaction in bulb alkaline. No growth in 
closed arm. Saccharose and Lactose also not fermented by 
this organism. 

Blood Serum. — Abundant white or reddish-white growth. No 
liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus MiTk. — Acidification and coagulation within forty-eight 
hours, followed by rapid digestion of the casein and reduction 
of the litmus. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 253 

46. BACTERIUM IMPLECTANS, Burchard, 1898. 

Literature. — Burchard, 1897, Beitrage zur Morphologie und Ent- 
wickelungsgesckichte der Bakterien, Inaugural Dissertation. 
Burchard, 1898, Arbeiten aus dem bakt, Inst. d. Techn. 
Hochschule zu Kalsruhe, Bd. II, p. 29. Migula, 1900, Sys- 
tem der Bakterien, p. 284. 

First isolated by Burchard from drinking water. 

Morphology. — Bacteria measuring 0.5-0.75 by 3-4.0 microns, grow- 
ing in long chains and showing polar granules. 

Motility. — Non-motile. 

Spores. — Formed rapidly on all media. 

Agar Slant. — Dull grayish-white growth wrinkling in old cultures. 

Agar Colonies. — Deep colonies, round and regular, yellowish ; 
superficial colonies spread over the surface of agar with 
white opaque centers, and grayish filmy irregular margin s, 
often assuming bizarre shapes. 

Broth, — Turbidity without scum. 

Gelatine Stab. — Rapid and complete liquefaction with the forma- 
tion of a heavy scum on the surface. 

Gelatine Colonies. — Deep colonies, small, round and brownish; 
superficial colonies spreading, grayish, skein-like, rapidly 
liquefying the gelatine plate. 

.Potato. — Luxuriant white growth, rarely becoming yellowish- 
brown. 

Fermentation Tube: Dextrose Broth. — Turbidity and sediment in 
bulb. Reaction in bulb acid. Growth in closed arm with the 
production of acid, but no gas. 

Saccharose and Lactose not fermented. 

Blood Serum, — Abundant white growth, without liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Produced in small quantities. 

Fecal Odor. — [Not produced. 

Litmus Milk. — Acidity and coagulation within forty-eight hours, 
with digestion of the casein and reduction of the litmus. 

47. BACILLUS CEREUS, Frankland, 1887. 

Literature. — Grace & Percy Frankland, 1887, Studies on some 
new Micro-organisms obtained from Air, Philosophical 
Trans, of the Royal Society of London, Vol. CLXXVIII B., 
p. 279. Migula, 1900, System der Bakterien, p. 537. Ches- 
ter, 1901, Manual of Determinative Bacteriology, p. 278. 



254 EXAMINATION OF THE FECES. 

First isolated from the air by the Franklands. 

Morphology. — Long, thick bacilli, measuring 0.75 v by 2-4.0 
microns in dimensions, not showing polar staining. Fre- 
quently growing in long chains. 

Motility. — Actively motile. 

Spores. — Formed rapidly on all media. 

Agar Slant. — Abundant growth, at first white and glistening, later 
becoming a dirty brown. Not dull or wrinkled. 

Agar Colonies. — Deep colonies, round, regular and grayish; 
superficial colonies spread over the surface of the agar, 
showing dark centers and outlying gray peripheries, an.d 
assuming diverse bizarre shapes. 

Broth. — Turbidity and scum. 

Gelatine Stab. — Abundant growth. Rapid and complete liquefac- 
tion. 

Gelatine Colonies. — Deep colonies, small, round and regular: 
superficial colonies have dark centers and spreading periph- 
eries made up of long, thin threads. 

Potato. — Faint, scanty white growth. 

Fermentation Tube: Dextrose Broth. — Turbidity and heavy scum 
in bulb. Reaction alkaline. No growth in closed arm. 

Saccharose and Lactose not fermented. Abundant scum 
on all sugar media. 

Blood Serum. — Abundant white, moist growth without liquefac- 
tion. 

Nitrates. — Not reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — No preliminary acidity. Alkaline reaction. No 
coagulation. 

Digestion of the casein and reduction of the litmus. 

48. BACILLUS MYCOIDES, Flugge, 1886. 

Literature. — Flugge, 1886, Die Mikroorganismen, 2 Aufl. Migula, 
1900, System der Bakterien, p. 538. 

Isolated from water and soil by Flugge. 

Morphology. — Bacilli measuring 1-1 14 by 3-4 microns in dimen- 
sions, occurring in pairs and chains. 

Motility. — Actively motile. 

Spores. — Formed rapidly on all media. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 255 

Agar Slant. — Growth along line of inoculation dull, wrinkled and 
tenacious, with difficulty raised from the surface of the agar, 
into which it sinks for a considerable depth. 

Agar Colonies. — Deep colonies, round, regular and opaque; super- 
ficial colonies spread over the surface of the agar assuming 
diverse sizes and shapes, but gradually fusing and forming a 
thick network. 

Broth. — Turbidity and wrinkled scum. 

Gelatine Stab. — Rapid and complete liquefaction,, with a heavy 
scum on the surface. 

Gelatine Colonies. — Deep colonies, round, regular and opaque ; 
superficial colonies, bluish-gray, with light opaque centers and 
dark spreading peripheries. As colonies become older they 
coalesce, forming a skein-like mycelium. 

Potato. — Thick white abundant growth. 

Fermentation Tube: Dextrose Broth, — Turbidity in bulb, with a 
heavy scum on the surface. Reaction acid. Growth in closed 
arm with the production of acid but no gas. 
Saccharose and Lactose not fermented. 

Blood Serum. — Abundant white growth. No liquefaction, 

Nitrates. — Reduced to nitrites. Heavy scum on nitrate broth. 

Indol. — Xot produced. 

Fecal Odor. — Xot produced. 

Litmus Milk. — Preliminary acidity followed by an alkaline reac- 
tion. Xo coagulation. Digestion of the casein and reduction 
of the litmus. 

49. BACTERIUM LACTICOLA, Migula, 1900. 

Literature and Synonym. — Fliigge, 1894, Die Aufgaben und Leis- 

tungen der Milchsterilisierung gegeniiber die Darmbakterien 

des Sauglings, Zeitschr. f. Hygiene, Bd. XVII, p. 294. 

Bacillus lactis. No. V. — Kruse, 1896. Fliigge,. Die Mikro- 

organismen, 3 Aufl, Bd. II, p. 28. Migula, 1900, System 

der Bakterien, p. 305. 

First obtained by Fliigge from milk. 
Morphology. — Long, thin bacteria measuring 1.0 by 3-5.0 microns, 

occurring in short chains and showing polar staining. 
Motility. — Xon-motile. 
Spores. — Formed quickly on all media. 

Agar Slant. — Dull wrinkled growth in young cultures, rapidly 
spreading over whole surface of the agar. 



256 EXAMINATION OF THE FECES. 

Agar Colonies. — Deep colonies/ regular and opaque; superficial 

colonies spread over the surface of the agar, assuming diverse 

shapes and producing a grayish coloration. 
Broth, — Turbidity and a wrinkled scum. 
Gelatine Stab. — Rapid and complete liquefaction. 
Gelatine Colonies. — Grayish-brown colonies with many spreading 

processes, producing a rapid liquefaction of gelatine. 
Potato. — Abundant creamy-white or reddish-white growth. 
Fermentation Tube: Dextrose Broth, — Turbidity in bulb with a 

wrinkled scum. Reaction in bulb alkaline. ~No growth in 

closed arm. 

Saccharose and Lactose not fermented. 
Blood Serum. — Abundant white growth. Rapid and complete 

liquefaction. 
Nitrates. — Reduced to nitrites. 
Indol. — Not produced. 
Fecal Odor. — JSTot produced. 
Litmus Milk. — Acidification and coagulation. Peptonization of 

the casein and reduction of the litmus. 

50. BACTERIUM VERMICULAKE (Frankland, 1889), Migula, 1900. 

Literature and Synonym: Bacillus vermicularis, Frankland, 
Grace and Percy, 1889. — Ueber einige typische Micro-organ- 
ismen in Wasser und Boden, Zeitschr. f. Hygiene, Vol. VI, 
p. 384. Migula, 1900, System der Bakterien, p. 302. 
Bacterium vermiculare (Frankland, 1889). — Chester, 1901, 
Manual of Determinative Bacteriology, p. 193. 
Obtained from air by Frankland. 

Morphology. — Bacteria very long and thin, measuring 0.5 by 6-8,0 
microns, often growing in long chains. 

Motility. — Non-motile. 

Spores. — Formed rapidly on the usual media. 

Agar Slant.- — Grayish-white and glistening dull growth, never 
becoming wrinkled. 

Agar Colonies. — Deep colonies, round, regular, opaque; super- 
ficial colonies, grayish, spreading, various shapes and sizes. 

Broth. — Turbidity, no scum. 

Gelatine Stab. — Rapid and complete liquefaction. 

Gelatine Colonies. — Gray, spreading, irregular colonies forming a 
network on the surface. 

Potato. — Luxuriant reddish or flesh-colored growth. 



BACTERIOLOGICAL EXAMINATION OF TEE FECES. 257 

Fermentation Tube: Dextrose Broth. — Turbidity and sediment in 
bulb. Reaction in bulb acid. Growth in closed arm with the 
production of gas. 

Saccharose and Lactose not fermented. 

Blood Serum. — Abundant reddish growth, causing a complete 
liquefaction of the blood serum. 

Nitrates. — Keduced to nitrites. 

Indol. — Xot produced. 

Fecal Odor. — Xot produced. 

Litmus Milk. — Rapid acidification and coagulation of the milk, 
peptonization of the casein and reduction of the litmus. With 
some cultures the amount of acidity is not great, the milk 
turning red, later to a deep purple, after which coagulation 
sets in. 

51. BACILLUS VULGATUS, Trevisan, 1889. 

Literature and Synonym: Bacillus mesentericus vulgatus. — 
Fliigge, IS 8 6, Mikroorganismen, 2 Aufl. Eisenberg, 1891, 
Bakteriol. Diagnostik, 3 Aufi. 
Bacillus vulgatus. — Trevisan, 1889, Geneva, p. 19. 
Bacillus vulgatus (Flugge) Mig. — Migula, 1900, System der 

Bakterien, p. 556. 
Bacillus vulgatus, Trevisan. — Chester, 1901, Manual of 

Determinative Bacteriology, p. 271. 
Potato bacillus of various authors. 

Morphology. — Bacilli measuring 0.5 by 3-4.0 microns, appearing 
as single elements without polar staining. 

Motility. — Actively motile. 

Spores. — Formed quickly on all media. 

Agar Slant. — Abundant, thick, moist growth, in old cultures 
becoming grayish and crumpled. 

Agar Colonies. — Deep colonies, round and regular; superficial 
colonies, grayish, irregular, forming thick centers and thin, 
irregular prolongations. 

Broth. — Turbidity and thick wrinkled scum. 

Gelatine Stab. — Rapid liquefaction, with the formation of a sur- 
face membrane. 

Gelatine Colonies. — Deep colonies, round and regular; superficial 
colonies have white opaque centers and outlying prolonga- 
tions which form a thick skein. 

Potato: Characteristic appearance. — Luxuriant heaped-up, pink 

17 



258 EXAMINATION OF THE FECES. 

growth made up of long processes, which cover the entire sur- 
face of the potato with a corrugated mass. 

Fermentation Tube: Dextrose Broth. — Turbidity and membrane 
in bulb. Alkaline reaction in bulb. No growth in closed 
arm. 

Saccharose and Lactose not fermented. 

Blood Serum. — Abundant growth. Complete liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — No preliminary acidity. Rapid production of 
alkali. No coagulation. Peptonization of the casein and 
reduction of the litmus. 

52. BACILLUS BREVIS, Migula, 1900. 

Literature and Synonym: (Bacillus No. 1). — Fliigge, 1894, Die 
Aufgaben und Leistungen der Milchsterilisierung, Zeitschrift 
fiir Hygiene, Bd. XVII, p. 294. Migula, 1900, System der 
Bakterien, p. 583. 

First obtained by Fliigge from milk. 

Morphology. — Long, thin bacilli measuring 0.5 by 3.0 microns, 
often appearing in long chains. 

Motility. — Actively motile. 

Spores. — Rapidly formed on the usual -media. 

Agar Slant. — Abundant soft glistening brown growth covering 
whole surface and not becoming dull or wrinkled. 

Agar Colonies. — Deep colonies, round and regular; superficial 
colonies, round, opaque, non-spreading. 

Broth. — Turbidity without scum. 

Gelatine Stab. — Slow but complete liquefaction. 

Gelatine Colonies. — Round, irregular, brown colonies, often form- 
ing a network of fine threads. 

Potato. — Little or no growth. 

Fermentation Tube: Dextrose Broth. — Turbidity and sediment in 
bulb. Reaction alkaline. No growth in closed arm. 
Saccharose and Lactose not fermented. 

Blood Serum. — Abundant growth with complete liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — Slight acidity without coagulation, followed by 
digestion of the casein and reduction of the litmus. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 259 

53. BACILLUS SUBTILIS (Ehrenberg 1838), Cohn, 1872. 

Literature and Synonym: Vibrio subtilis. — Ehrenberg, 1838, 

Infusionsthierschen als volkomrnene Organismen, Leipzig. 

Bacillus subtilis. — Colin, 1872, Beitrage zur Biologie, Bd. I, 
p. 175. 

Bacillus subtilis (Ehrenberg), Cohn. — Migula, 1900, System 
der Bakterien, p. 515. 

Bacillus subtilis (Ehrenberg), Cohn. — Chester, 1901, Manual 
of Determinative Bacteriology, p. 276. 

First obtained by Ehrenberg from air and water. 
Morphology. — Bacilli measuring 0.5 by 1-6.0 microns, without 

polar staining, appearing rarely in short chains. 
Motility. — Actively motile. 

Spores. — Formed rapidly, lying in the centers of the bacilli. 
Agar Slant. — Glistening, dull white, sticky, matted tenacious 

growth. 
Agar Colonies. — Deep colonies, round and regular; superficial 

colonies spread slightly, with opaque white centers assuming 

various bizarre shapes. 
Broth. — Turbidity and heavy scum. 
Gelatine $£a&.-^-Abundant growth, with a rapid liquefaction and 

a heavy scum on the surface. 
Gelatine Colonies: Characteristic appearance. — Deep colonies, 

round, regular and opaque ; superficial colonies spreading 

with dense black centers and grayish-outlying threads. 
Potato. — Luxuriant, thick, grayish or yellowish-brown growth,, 

which in old cultures forms a corrugated stringy mass cover- 
ing the whole surface of the potato. 
Fermentation Tube: Dextrose Broth. — Turbidity and sediment in 

bulb. Reaction in bulb acid. Growth in closed arm with the 

production of an acid reaction but no gas. 
Saccharose and Lactose not fermented. 
Blood Serum. — Abundant white growth. Rapid liquefaction. 
Nitrates. — Reduced to nitrites. 
Indol. — Not produced. 
Fecal Odor. — ~Not produced. 
Litmus Milk. — Rapid acidification and coagTilation of the milk; 

peptonization of the casein and reduction of the litmus. 



260 EXAMINATION OF THE FECES. 

54. BACILLUS ARACHNOIDEUS, Migula, 1900. 

Literature and Synonym: (Bacillus No. 111). — Fliigge, 1894, 
Die Aufgaben und Leistungen der Milehsterilisierung, Zeit- 
schrift Mr Hygiene, Bd. XVII, p. 294. Migula, 1900, Sys- 
tem der Bakterien, p. 583. 

! First isolated by Fliigge from milk. 

Morphology. — Fine bacilli measuring 0.5 by 2.0 microns. No 
polar staining, often grows in short chains. 

Motility. — Actively motile. 

Spores. — Formed rapidly on the usual media. 

Agar Slant. — Dull, wrinkled, tenacious growth, sinking deeply 
beneath the surface of the agar. 

Agar Colonies. — Deep colonies, round and regular; superficial 
colonies, grayish, spreading, with white opaque centers. ' 

Broth. — Turbidity without scum. 

Gelatine Stab. — Rapid liquefaction. 

Gelatine Colonies. — Deep colonies, regular, uniform; superficial 
colonies, slightly spreading, grayish with opaque centers, 
somewhat resembling colonies of Bacillus subtilis. 

Potato. — Luxuriant yellowish-brown growth, forming huge blebs. 

Fermentation Tube: Dextrose Broth. — Turbidity and sediment in 
bulb. Reaction in bulb acid. Abundant growth in closed arm 
with the production of an acid reaction but no gas. 

Saccharose fermented with the production of acidity 

and a small quantity of gas. 
Lactose not fermented. 

Blood Serum. — Abundant white growth. Rapid liquefaction. 

Nitrates. — Reduced to nitrites. 

Indol. — Not produced. 

Fecal Odor. — Not produced. 

Litmus Milk. — Acidity and coagulation of the milk within forty- 
eight hours. Peptonization of the casein and reduction of the 
litmus. 



Other bacteria which have been found in the feces, but the full 
descriptions of which cannot be here included, are : 

55. Bacillus aquatilis sulcatus. 

Short motile bacilli, no spores, obligate anaerobes. Gram. — ; 
small, superficial, opalescent colonies, not liquefying gelatine. A 
yellow pellicle on potatoes. No indol. No fermentation of sugar. 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 261 

No coagulation of milk. Described by Weichselbaum ; five types 
belonging to the typhoid group. 

56. Bacillus coll immobilis. 
Biological characters those of Bacillus coli, but immobile. 

57. Bacillus coprogenes parvus. 

Short, immobile forms, staining most intensely at the extremi- 
ties. No spores. Anaerobic. Gram. — . Gelatine plates: small, 
round, light brown, non-liquefying colonies. Gelatine stab: nail- 
shaped growth. Agar : thin, white colonies. Potato : gray pellicle. 
Bouillon is clouded. Milk, coagulated with acid formation. Indol 
formed. Pathogenic for mice and rabbits. 

57. Bacillus -fcetidus. 

Various lengths. Motile. Large spores. Gelatine: large colo- 
nies liquefied. 

58. Bacillus oedematis oerobius. 

Various sized bacilli. Motile. Facultative anaerobes. Gelatine 
plates: superficial, transparent, opalescent colonies, with wavy 
margins; deep colonies, round and yellow. In gelatine stabs 
develop stinking gas. Potatoes: dirty gray pellicle. Bouillon 
turbid. Pathogenic for guinea pigs, etc., with production of a 
bloody, oedematous infiltration. 

58. Bacillus putrificus. 

Long (5-6 micra), narrow bacilli. Actively motile. End spores 
anaerobic. Gelatine stab: single colonies, with gas bubbles, which 
later coalesce; liquefaction. Plates: yellow, opalescent colonies. 
Gram. -f-. Spore formation. The bacillus of proteid decomposition. 

59. Bacillus tuberculosis (Koch). 

Slender, slightly curved formed; non-motile. Generally single 
or parallel; short threads also. No spores. Acid-fast. Stained 
according to Ziehl-Neelson. Gram. +. iErobic. For further char- 
acters, see text-books. 

59. Bacillus phlei. 

Short, thick bacilli, often enlarged at one extremity. Non- 
motile. Stain as tubercle bacilli (acid-fast), but also easily with 



262 EXAMINATION OF THE FECES. 

methylene blue. Growth is far more active than in case of tubercle 
bacillus, and proceeds at temperatures of 20-25 degrees. Gela- 
tine plates: small, white, irregular colonies. Agar plates: slight 
growth. Glycerine agar, dense, orange-yellow, plicated growth. 
Bouillon pellicle, no turbidity. 

60. Bacillus Breslaviarms. 

Short, motile bacilli. ~No spores. Gram. — . Growth resem- 
bles coli, except that milk is not coagulated, and no indol is 
formed. Gas fermentation. 

STREPTOCOCCI. 

61. Streptococcus coli gracilis. 

Found in feces and meconium. Temperature 0. 39°. Gelatine 
plates : small, round colonies, which rapidly liquefy the medium.- 
Gelatine stab: stocking-like liquefaction. Agar: slight growth. 
Potatoes : small, white, slightly-raised colonies. Non-pathogenic. 

62. Streptococcus coli orevis. 

Found in milk, and in the feces of milk-fed infants. Small 
cocci, grouped in short chains, the chains often containing single 
larger forms (so-called megacocci). Gelatine plates: rounded col- 
onies, with shallow, saucer-like liquefaction; center olive-green. 
Agar: greenish-yellow growth. Blood serum: citron-yellow colo- 
nies, no liquefaction. 

63. Streptococcus pyogenes. 

The typical cocci of suppurative processes. May be arranged in 
long chains (S. longus) , or in network (S. conglomeratus ) , or in 
short chains (8. brevis). Gram. +. Facultative anaerobe. Gel- 
atine plates : small, transparent colonies, with fine granulation, 
slightly-raised border, no liquefaction. Gelatine stab: granular 
growth. Agar plates : as in gelatine, but larger. Agar stab: small, 
isolated colonies along stab, often a delicate surface growth. 
Potato: no growth. Bouillon: generally clear; sediment. Milk, 
coagulated. 

STAPHYLOCOCCI. 

Staphylococci are grouped, according to the coloring matter 
produced by their colonies, as : 



BACTERIOLOGICAL EXAMINATION OF THE FECES. 263 

64. Staphylococcus albus. 
No coloring matter. 

65. Staphylococcus aureus. 
Golden-yellow coloring matter. 

QQ. Staphylococcus citreus. 
Citron-yellow coloring matter. 

The following types of vibriones have been described : 

SPIRILLA. 
67. Spirillum cholera? Asiaticce. 

Three-quarters to two micra long, thickness one-tliird of length. 
S and E forms occur; threads and spirilli occur only under cir- 
cumstances unfavorable to growth. Monotrichons, motile. No 
spores. Facultative anaerobes. Gram. — . Gelatine plates: in 
twenty-two to twenty-four hours, . barely visible colonies, which, 
under weak magnification, appear as light yellow, granulated, 
irregularly-rounded colonies, flattened, with slightly raised border. 
Rapid growth ; delicate marginal processes, center yellowish ; 
liquefaction. Colonies shimmer, but zone of liquefaction is dull, 
and contains grayish fragments. Gelatine stab: growth along 
stab, with tube-like liquefaction, funnel-like liquefaction at sur- 
face. Agar plates: grayish brown, transparent, rounded colonies. 
Agar slant: grayish-white growth. Blood serum: liquefied. 
Bouillon : turbidity and pellicle. Cholera-red reaction : on addition 
of a few drops of pure, strong H 2 S0 4 to a twenty-four hours' 
bouillon growth. Pathogenic for guinea pigs, etc. 

6S. Spirillum Gottschlich (Cholera Nostras) . 
Growth on all media very similar to Cholerse Asiaticse. No 
nitrosoindol, but only indol reaction. Almost all cultures develop, 
much H 2 S. 

69. Spirillum helcogenes. 
Found in diarrhea. Similar to bacillus proteus. No nitrosoin- 
dol reaction. 

70. Spirillum Lisbon. 

Found in an epidemic in Lisbon. 

71. Spirillum Massanah. 
Found in a case resembling cholera in Massanah. 
72. Spirillum proteus (Finkler Prior). 
For full details regarding these forms, reference must be had to 
Migula, or other bacteriological system. 



CHAPTER XVII. 

ANIMAL PARASITES— PATHOLOGICAL FORMS. 
PROTOZOA. 

The protozoa have of recent years assumed a role of some im- 
portance in the etiology of intestinal disease, and of this group of 
animalcules, by all odds the most important is the Amoeba. 

This rhizopod appears, like so many other pathogenic forms, to 
be a harmless denizen of the gut under ordinary circumstances. 
At all events, it is possible to find amoebae in the stools of perfectly 
normal individuals. They increase in number as the stools 
become more alkaline in reaction, as, for example, when Rochelle 
salts are taken daily. 

The amoeba occurs in the stools in enormous numbers, chiefly 
imbedded in the mucus, in certain forms of dysentery. Not only is 
,it found in the stools, but pathological examination of the ulcers 
in the intestine discloses the fact that the organism has worked its 
way into the ulcers, and has invaded the deeper layers of the 
intestine. 

Notwithstanding these facts, there has always been a school of 
pathologists which asserts that the amoeba is not the actual cause 
of the disease, but a mere saprophyte, which thrives under the 
conditions presented by the intestinal contents in cases of so-called 
amoebic dysentery. This school is of the opinion, then, that some 
other organism, possibly streptococcus, which occur in large 
numbers in many cases of the disease, is the real causa morbi, and 
the amoeba simply a harmless symbiote. They would compare its 
role to that of the Aspergillus, which is occasionally found luxur- 
iantly growing in the lung cavities which have been produced by 
the action of the tubercle bacillus. That there is some ground for 
this theory cannot be disputed. Indeed, the history of coprology 
presents several instances of similar fallacious conclusions. 

On the other hand, there are certain arguments which speak 
very strongly for the pathogenic and etiological role of the 
amoeba in these dysenteries. 

If the mucus be collected and freed from the contaminating 
feces, and be then injected into the rectum of cats, or rabbits, in 

-(264) 



ANIMAL PARASITES— PATHOLOGICAL FORMS. 265 

almost every instance a severe colitis is set up in the animal within 
a very few days, which generally runs a rapidly fatal course. 

The autopsy discloses a severe ulcerative and diphtheritic dys- 
entery, and the amoeba are found deeply imbedded in the base of 
the ulcer. Still more conclusive is the evidence derived from the 
so-called amoebic abscesses of the liver, which complicate the dysen- 
tery. These abscesses are almost invariably characterized by a 
peculiar set of symptoms which distinguish them from those of 
bacterial origin. They are, as a rule, very chronic and slow in 
growth. They give rise to a leucocytosis which is comparatively 
low, ranging from 10,000 to 17,000, rarely above 20,000. They 
are sterile when inoculated on the media in curient use, and 
when stained in smear reveal no bacteria. Most striking of all, 
is the fact that scrapings from the walls of these liver abscesses 
very frequently contain amoebae, and that these scrapings, when 
injected into cuts per rectum, again set up an amoebic colitis. Thus 
the chain of circumstantial evidence is strongly in favor of an inti- 
mate pathogenic connection of the amoeba with the colitis with 
which it is associated. A final and practical conclusion of great 
importance is the fact that the disease yields in a manner almost 
specific, and unknown in any of the bacillary infections, to the 
method of irrigation by quinine, a drug which exerts a peculiar, 
deleterious action on many rhizopods and other microzoa. The 
dispute could be settled finally and beyond doubt only by securing 
pure cultures of the amoeba, and then reproducing the lesions ex- 
perimentally, according to the demands of Koch's requirements. 
Unfortunately, this is a desideratum which cannot be accom- 
plished, owing to the fact that the amoeba does not live 'on our 
sterile media, but requires living pabulum. In view of this diffi- 
culty, the circumstantial evidence in favor of the pathogenicity 
of the amoeba must be accepted provisorally at least, as satisfactory. 

The methods of examining the feces for amoeba require a cer- 
tain amount of care. The stool should always be secured in a per- 
fectly fresh condition, inasmuch as the amcebse very rapidly die 
off in a stool which has been preserved over a few hours, even if 
the precaution be taken of keeping it at body temperature in the 
incubator. The fresh stool, then, is examined, and a particle of 
mucus, preferably streaked with blood, is selected and placed on a 
slide, which should be chemically clean. In adjusting the cover- 
glass, it is wise to insert between cover and slide a horse-hair, or 
some similar object, in order not to crush the organisms or inter- 
fere with their locomotion, which is their most characteristic 



266 



EXAMINATION OF THE FECES. 



feature. This simple method suffices for all ordinary diagnostic 
purposes in most cases. In case the room in which , the micro- 
scopical examination is carried on is at a temperature below 
75° F., a more elaborate mechanism, known as the warm 
stage^ must be employed in the examination. This is an apparatus 
manufactured by most dealers in microscopical supplies, in 
which a cell ground out in a glass chamber is kept at an even tem- 
perature by a continuous flow of water from a reservoir. The 
mechanism is very simple, and by its means the particle to be 
examined can be kept at body temperature for an indefinite period 
of time. This allows of a prolonged study of the amoeba, its 
mode of movement, of ingestion, and its thanatology. 



Fig. 85. 







Amoeba coli. (Mosler.) 



An extremely important point in the biology of the organism, 
namely, its mode of self -perpetuation, has, unfortunately, not yet 
been cleared up by the use of this method. 

Under the low power of the microscope, the organisms are at 
once recognizable, both by their size, and by their active pseudo- 
podial movement. They vary in size from 10 to 50 micromilli- 
meters, the majority being far larger than the largest leucocytes 
or epithelial cells by which they are surrounded In a resting 
condition they are rounded or ovoidal in shape, with somewhat 
irregular margins. In motion, they present one or more slender 
arm-like prolongations, "the pseudopods." As a rule, the warmer 
the stage, the more active is this pseudopocl formation. The organ- 
ism extends an arm, or process, and its protoplasm, either slowly 



ANIMAL PARASITES— PATHOLOGICAL FORMS. 



267 



or with great rapidity, follows the path so laid out, and "streams" 
along after the pseudopod in a very characteristic fashion. The 
protoplasm is composed of two parts, a clear hyaline enveloping 
layer, of the diameter generally of less than one micromillimeter, 
known as the "ectosarc," and a coarsely granular interior, which 
makes up the vast bulk of the organism, the "endosarc." The endo- 
sarc consists apparently of a fluid matrix in which are numerous 
refractile coarse granules, which are, by some, supposed to repre- 
sent the nodal points of a reticulum. Imbedded in the proto- 
plasmic mass is a nucleus, which is not always distinctly to be 
made out. On the addition of acetic acid it becomes sharp and 
prominent. 

In addition to these elements, which belong to the protoplasm 

Fig. 86. 





Balantidium coli. 1. 2, division ; 3, conjugation. (After Leuekart, from Doflein.) 

proper, the organism contains a large amount of ingested material, 
bacteria and detritus, and, in cases of dysentery, red blood cells in 
various stages of disintegration. It also contains numerous small, 
clear, rounded vesicles, the "vacuoles." Of these, a small num- 
ber may be seen alternatingly to contract and expand, and are 
known as ''pulsating vacuoles." Their function, which is not posi- 
tively known, may possibly be respiratory. Spore-formation in 
amoeba, which would offer a valuable clue in the study of the 
epidemiology of the disease, has been a subject of much research, 
with little result. Various investigators have reported encystment 
of the amoeba?, and endogenous spore-formation, but their results 
are not yet established beyond cavil. 

Several types of amoeba have been distinguished, based upon 



268- 



EXAMINATION OF THE FECES. 



the degree of their pathogenicity. These are, (1) the Amoeba coli, 
Loesch, (2) Amoeba coli mitis, and (3) Amoeba intestini vulgaris. 
It is, unfortunately, impossible to distinguish these forms, which 
are apparently essentially different from a pathogenic standpoint, 
by their morphological characters. 

The first, Amoeba coli, Loesch, is the true cause of dysentery, 
occurs in large numbers in the mucus, contains red blood cells, and 
is very fatal to cats. 

Amoeba intestini vulgaris is the common and harmless symbiote 
which inhabits the normal gut. It occurs sparsely, except in very 
alkaline stools, is not associated with mucus, is harmless for cats. 



Fig. 81 



Fig. 88. 





Balantidium minutum. 
(After Schaud inn, from Doflein.) 



Nyctotherus faba. 
(After Schaudinn, from Doflein.) 



Amoeba coli mitis is associated with certain non-dysenteric 
catarrhs, and is not fatal to cats. It holds a position intermediate 
between the two first named varieties. 

The method of injecting pats is very simple. A small part of 
the fluid stool, containing shreds of mucus, is injected through an 
ordinary small caliber catheter introduced 2 to 3 inches up the 
rectum. It is best then to sew up the anus of the animal for a 
day or two, in order to prevent the expulsion of the irritant 
material. 

Another protozoan which seems almost certainly to stand in 
etiological relationship to certain forms of dysentery is the 
Balantidium coli. 

Here, again, the same difficulties as in the case of the amoeba 



ANIMAL PARASITES— PATHOLOGICAL FORMS. 



269 



interfere with the absolute proof of the pathogenicity of the organ- 
ism. The strongest argument in favor of this view is the fact that 
it is found deep down in the submucosa in connection with ulcers 
of the colon. It is an accompaniment of a very severe form of dys- 



Fig. 







Cercomonas coli hominis. (After May, from M osier.) 

Fig. 90. 





Megastoma entericuro. (From Mosler.) 

entery, of which the great majority of cases have been reported 
from Sweden and Russia. 

The Balantidium is a normal and harmless denizen of the colon 
of the pig, and, it is supposed, is transferred to human beings in the 
process of preparing sausages. 



270 EXAMINATION OF THE FECES. 

Balantidium coli is of an oval shape, 60 to 100 micromillimeters 
long, 50 to 70 broad, and almost completely covered with short, rap- 
idly vibratile cilia?. The month is funnel-shaped, and surrounded 
by long, somewhat stiffer cilia. The anus lies at the opposite 
extremity. Ectosarc and endosarc are sharply separated. The 
latter is coarsely granular, and contains a kidney-shaped nucleus, 
generally two contractile vacuoles, and paraplasm in the shape of 
detritus, starch granules, etc. Encysted forms have been described. 
Motion is extremely rapid, so much so that it cannot be followed 
under the microscope. The organism dies very quickly, and frag- 
ments. 

Other forms of doubtful interest in disease are, Balantidium 
minutum, Nyctothervs faba, Coccidium hominis, Trichomonas 
intestinalis, Cercomonas liominis, and Megastoma entericum. 

WORMS. 

The diagnosis of helminthiasis from the stools may be so easy as 
to be evident even to the laity, or it may require a considerable 
amount of painstaking research. 

If segments of the Taenia pass in the stool, the diagnosis is 
quite patent. In other cases, suspicion of the presence of worms 
can be confirmed only by a thorough examination of the stools for 
eggs. 

In the search for eggs, diarrheal stools may be examined with- 
out further preparation under the microscope. The more solid 
feces must be rubbed up with water, but without the use of much, 
violence, and then examined. Where Oxyuris is suspected, the 
examination often succeeds best, if fecal matter is removed from 
around the anus by means of a spatula, by -the introduction of the 
finger just within it. In this manner not only the eggs, but even 
the worms themselves are often removed. In case the search for 
eggs is fruitless, success often follows the administration of a dose 
of some laxative, such as castor oil. As a last resort, the diagnosis 
must be made ex juvantibus, by the examination of the stool after 
the administration of one of the vermifuges. 

In case of suspected Ascaridw, this procedure offers no objec- 
tions, inasmuch as the therapeutic dose of santonin is usually innoc- 
uous. 

The cure of Tcenia, however, is always a serious matter, and 
the course should not be lightly undertaken, simply on suspicion. 



ANIMAL PARASITES— PATHOLOGICAL F0E3IS. 271 

It is far wiser to give a small close of the teniafuge, say one-third 
of the therapeutic dose of extract of male fern, which generally suf- 
fices to drive portions of the worm out with the feces. The cor- 
roborative value of eosinophile cells and Charcot-Leyden crystals 
in the stool has already been mentioned in an earlier section. 
Eosinophilia in the blood should not be forgotten. 

The worms which occur in the feces belong to three sub-orders, 
the Trematodes and Cestodes of the Platlielminthes, and the Nem- 
atodes of the N emathelminthes. 

Nematodes. — The nematodes are round worms, and include the 
following found in human beings: Ascaris lumbricoides, 
Oxyuris vermicularis, Anchylostoma (JJncinaria) duode- 
nale, Anchylostoma (JJncinaria) Americana, Tricliocephalus dis- 
par. Trichina spiralis, Anguillula intestinalis and Anguillula 
stercoralis. 

All these worms are rounded, their bilateral symmetry being 
generally expressed by some external character. The sexes are dis- 
tinct. There is no alternation of generations, but the mature indi- 
viduals are derived in. the same form from the egg. The body is 
unsegmented. The cuticle is thick and elastic. The mouth is 
terminal, and armed with "labia" which may be very hard. The 
gut traverses the entire body, and the anus lies near the posterior 
extremity. 

The generative organs and their openings lie on the ventral 
surface. The female genital pore generally lies about midway. 
The male opening is conjoined with the anus. The male is gener- 
ally smaller than the female. The nematodes parasitic in man 
are in part harmless parasites of the gut, in part very dangerous 
invaders which may find their way into the various viscera, and 
even cause death. 

Ascaiis lumbricoides is the most common parasite of the 
human intestinal canal, and often occurs as a multiple infection. 
These worms are found chiefly in the small intestine, but may 
find their way into the stomach, the bile passages, or out of the 
anus. The worm is cylindrical, the male ranging in length from 
10-25 cm., the female from 25-40 cm. The male is easily rec- 
ognized by the fact that the anal extremity is curved like a hook, 
and is armed with a couple of spicules of chitin. The color of the 
worm is a brownish-red or yellow. The oral opening is surrounded 
by three muscular lips which carry very fine teeth. The eggs, from 
which alone the diagnosis must often be made, are carried in enor- 



272 



EXAMINATION OF THE FECES. 
Fig. 91. 




Ascaris lumbricoides. A, female; B, male; 0, egg; at a the female genital opening; c, 
the male spicules; b, the enlarged cephalic extremity, with its three lips. (After Perlo, from 
Ziegler.) 



ANIMAL PARASITES— PATHOLOGICAL FORMS. 273 

mous numbers by the female, and are constantly being passed off, 
to appear unaltered in the feces. 

The eggs are 50 to 70 micromillimeters in size. They are pro- 
tected by a double shell, and, outside of this, an albuminous 
envelope. 

As it appears in the feces, the egg shows no embryo, but only 
a homogeneous mass of granular protoplasm, yellowish in color. 

For its further development no intermediate host is necessary. 
The eggs may find their way to some source of water supply, and 
undergo further development, and may then be again taken into 
the stomach with the drinking water ; or they may be transferred 
by the finger directly from anus to mouth, a mode of infection 
undoubtedly common among children. 

If the egg still retains its albuminous envelope, it passes the 
stomach intact, and is only dissolved in the intestine. Here the 
immature egg undergoes further development, and within ten to 
twelve weeks arrives at sexual maturity. 

The diagnosis is made from the presence of the characteristic 
eggs in the feces, or from the parasites themselves. 

Oxyuris vermicularis, known also as the thread-worm, seat- 
worm, or pin-worm, is a very frequent parasite, especially in 
young children. 

It is an inhabitant of the colon, but may crawl out of the anus 
at night, and into the vulva. In this way, direct infections from 
child to child may occur. 

The worm is very minute, the male measuring 4 mm., the 
female 11. The female is easily distinguished. In addition to 
its greater length, it has a genital pore at about the middle of the 
ventral surface, the posterior extremity is drawn out to a point 
and, when pregnant, the body is literally stuffed with eggs. 

The eggs are 50 micromillimeters long, and 24 broad. They 
are asymmetrical, having a flat and a curved surface. They have 
a chitinous shell, covered by a layer of gelatinous material. The 
eggs are found in the feces, either as homogeneous masses of finely 
granular protoplasm, containing a small, clear nucleus with a 
nucleolus, or in various stages of embryonic development. For' 
their further development, it is requisite that the eggs be swal- 
lowed by some animal. The gastric juice dissolves the chitinous 
envelope, and sets free the embryo, which then completes its devel- 
opment, and finds its way to the intestine. No intermediate host 
occurs. 

So much that is incorrect has been written about the life-history 



274 



EXAMINATION OF THE FECES. 



of the worm within the intestine, and so much depends, thera- 
peutically, on the exact understanding of these phases, that it may 
be well to recapitulate the newer facts, recently brought together 
by Heller. 1 



Fig. 92. 



Fig. 93. 




a. b. 





1. Oxyuris vermicularis ; a, male; 6, female ; 
natural size. 2. Magnified. 

Fig. 94. 




Oxyuris vermicularis. a, sexually mature 
female ; b, female filled with eggs ; c, male. 
Magnification, 10. (After Heller, from 
Ziegler.) 



Eggs of Oxyuris vermicularis in various 
stages of development, a, b, c, division of 
the yolk; d, tadpole-like embryo; c, worm- 
shaped embryo. Magnification, 250. (After 
Zenker and Heller, from Ziegler.) 



Having passed the stomach and reached the intestine, the oxyuris 
undergoes several moults before it becomes sexually mature. Cop- 
ulation between the ripe worms immediately takes place, and is 
probably continued in the cecum and vermiform appendix, where 



1 Deutsches Archiv. f. klinische Medicin, July 28, 1903. 



ANIMAL PARASITES— PATHOLOGICAL FORMS. 275 

it is not unusual to find a great many mature worms of both sexes. 
The development of the eggs begins in the fertilized female. From 
the cecum, the female begins gradually to trace its way along the 
colon towards the rectum, the development of the contained 
embryos meanwhile proceeding apace. 

If these pregnant females be examined at the lower end of the 
rectum, they are found to be literally stuffed with eggs, each one 
containing a well-advanced organism, worm-like in shape, and 
capable of motility when set free from its envelope. These eggs are 
deposited in the rectum, and in and about the anus. They are 
then generally transferred by the finger to the mouth, the eggs pass 
on into the stomach, where the shell is dissolved, and the young 
embryos migrate into the small intestine. 

There are thus simultaneously three broods in the intestine — 
the young, incompletely-developed worm in the small gut; the 
copulating males and females in the cecum, and the pregnant 
females in the colon. 

Anchylostomum duodenale, also known as Dochimus duo- 
denalis, or Strongylus duodenalis, is generally described in Amer- 
ica as Uncinaria. Until a very few years ago it was generally 
believed that this parasite was practically limited to the Old 
World, occurring only sporadically in imported examples in this 
country. Very recently, however, it has been discovered that 
there are very many endemic cases both in our Southern States and 
in the recently-acquired island colonies. 

Warfield found 80 per cent, of the schoolboys in Savannah in- 
fected, and Ashford and King report that the parasite is responsi- 
ble for about one-third of the deaths occurring annually in Porto 
Rico. 

It is, indeed, no other than the same worm which was originally 
described by Bienner, in Switzerland, as the agent in pernicious 
anemia. 

There are, however, certain differences between the Old World 
and the American organism, which justify the erection of two 
distinct varieties or sub-species. The description given by Stiles, 
in Bulletin ~No. 10, Hygienic Laboratory, U. S. Public Health 
and Marine Hospital Service, is as follows : 

"The Old World hookworm, Uncinaria duodenalis: Body cylin- 
drical, somewhat attenuated anteriorly; buccal cavity, with two 
pairs of ventral teeth curved like hooks and one pair of dorsal 
teeth directed backward; dorsal rib not projecting into cavity. 



276 



EXAMINATION OF THE FECES. 



Male 8 mm. to 11 mm. long; caudal bursse, with dorso-median lobe 
and prominent lateral lobes united by a ventral lobe; dorsal ray 
divides at a point two-thirds of its length from its base, each 
branch being tridigitate ; spicules long and slender. Female, 



Fig. 96. 



Fig. 95. 





Anehylostoma duodenale, male and fe- 
male. Natural size. (From Mosler.) 



Eggs of Anehylostoma duodenale. a-d, 
various stages of segmentation; e, /, eggs 
containing embryos. Magnification, 200. 
(After Perroncito and Schulthess, from 
Ziegler.) 



Fig. 97. 




Head of Anehylostoma duodenale. a, buccal capsule; 6, teeth of capsule; c, teeth of dor- 
sal margin ; d, oral cavity ; e, ventral prominence ; /, muscle layer ; g, dorsal groove ; h, oeso- 
phagus. (After Schulthess, from Ziegler.) 



10 mm. to 11 mm. long; vulva at or near posteror third of body. 
Eggs ellipsoid, 52 micromillimeters to 60 micro-millimeters by 32 
micromillimeters, laid in segmentation. Development direct with- 



out intervening host. 



AXIJUAL PARASITES— PATHOLOGICAL FORMS. 
Fig. 98. 



277 




Male of Anchylostoma duo- 
denale. a, head ; 6, oesopha- 
gus; c, gut; d, anal glands; e, 
cervical glands; /, skin; g, 
muscular layer; h, excretory 
pore; i,tri-lobed bursa ; k, ribs 
of bursa ; I, seminal duct ; m, 
vesicula seminalis ; n, ductus 
ejaculatorius ; o, its groove ; p, 
penis; q, penile sheath. Mag- 
nification, 20. (After Schult- 
hess, from Ziegler. ) 



278 EXAMINATION OF THE FECES. 

"The New World hookworm, Uncinaria Americana, Stiles, 
,1902, of man: Body cylindrical, somewhat attenuated anteriorly; 
buccal capsule, with a dorsal pair of prominent semilunar plates or 
lips and a ventral 'pair of slightly-developed lips of a same nature; 
dorsal conical median tooth projects prominently into the buccal 
cavity. (The buccal cavity is thus markedly different from that of 
U. duodenalis.) Male, 7 mm. long; caudal bursa, with short dorso- 
median lobe, which often appears as if it were divided into two 
lobes, and with prominent lateral lobes united ventrally by an 
indistinct ventral lobe ; common base of the dorsal and dorso-lateral 
rays very short; dorsal ray divided to its base, its two branches 
being widely divergent, and their tips being bipartite; spicules 
long and slender. Female, 9 to 11 mm. long ; vulva in anterior half 
of body, but near equator (distinction from duodenalis). 

"Eggs ellipsoid, 64 micromillimeters to 76 micromillimeters 
long by 36 micromillimeters to 40 micromillimeters broad, in some 
cases partially segmented in utero, in others (rare) containing a 
fully developed embryo when oviposited." The eggs of the Ameri- 
can species are much larger than those of the Old World species. 

The eggs have a transparent shell, with a linear contour. As 
found in the feces, they very frequently present various phases 
of segmentation, up to the eight-celled stage. For further develop- 
ment, the eggs must find their way into moist earth, where they 
give rise to a rhabditiform embryo. This embryo undergoes at 
least two moultings before it is taken into the body of its host in 
drinking water, or in the dirt or clay which forms so prominent a 
part of the diet in certain districts of the South. 

In the intestinal canal,, the worm completes its full development, 
and becomes sexually mature. It inhabits especially the jejunum 
and duodenum, in the mucous membrane of which it fastens itself. 

The diagnosis is made by microscopical examination of the 
feces, in which the eggs are found, often in enormous quantities. 

The feces may be strained through gauze, as recommended by 
Smith. It is also justifiable in suspected cases to give a full dose of 
thymol, after which the parasite is found in the stool as small, 
thread-like bodies, y 2 to % of an inch long, of a grayish-red color. 

Strongyloides intestinaJis is a worm, the presence of which 
in the United States was first reported by Thayer. 1 Since then 
several cases have been reported. 

Little is known concerning the manner of infection. 

1 Journal of Experimental Medicine, November, 1901. Since then several cases 
have been reported. 



ANIMAL PARASITES— PATHOLOGICAL FORMS. 



279 



The life-history is somewhat complicated. From the ova develop 
a rod-like embryo, which may further develop into the sexually 
distinct adult forms. 

In temperate zones, however, the rod-like embryo generally 
passes into a thread-like stage, in which it enters the alimentary 
tract. Here it develops into a pathenogenetic female. The sexually 

Fig. 



Fig. 100. 





Anguillula intestinal is. 
from Ziegler.) 



(After Braun, 



Female of Anguillula stercoralis, with eggs 
and embryo. (After Perroneito, from Zieg- 
ler.) 

distinct adults copulate within the body and produce eggs which 
pass out in the feces, as do the eggs of the pathenogenetic form. 

Different names, producing a vast amount of confusion, have 
been given to these various phases of the same organism. The 
rhabditiform embryo is known as Strongyloides stercoralis, or 
Anguillula stercoralis ; the pathenogenetic female as Strongyloides 
intestinalis, and the mature forms which are sexually differen- 
tiated as Rhabditis stercoralis. 



280 EXAMINATION OF THE FECES. 

The diagnosis must be made from examination of the stool, 
which may contain either the rhabditiform or the filariform 
embryo. 

The eggs are rare, and the mature forms seem not to pass out 
in the feces. The rhabditiform embryo occurs as a briskly-moving 
worm, varying from % to % a millimeter (1-100 to 1-16000 of an 
inch) in size. It presents two slight ovoid enlargements of the 
body marked off by constrictions, and tapers to the tail. 

The filariform embryo is slightly longer, and does not show 
the above-mentioned varieties in caliber. Forms intermediate 
between these two have been described. The female worm is found 
post-mortem. 

Trichocephalus dispar, the "whip-worm," is a very widely- 
spread parasite. In Europe it occurs in 20 to 30 per cent, of all 
autopsies, but in America not so frequently. 

Its pathological status is not definitely settled, but it seems 
probable that it is a harmless parasite. 

As found at autopsies, it occupies the cecum and large intestine. 
It is about 5 cm. long, the male being a little shorter than the 
female. The shape of the worm is very characteristic ; the anterior 
portion of the body, more than one-half of the entire length, is 
extremely thin, while the posterior portion, which contains, the 
genital apparatus, is proportionally enormously thicker. In the 
female the posterior extremity is conical and pointed ; in the male 
it is curved like a watch spring, and armed with a spicule. The 
worms themselves, although they may occur in enormous numbers 
within the intestinal tract, are rarely seen in the feces. 

The eggs, on the contrary, furnish a frequent diagnostic evi- 
dence of the presence of the worm. They are oval, lemon-shaped, 
50 micromillimeters long. They are covered by a dense, brown 
shell, which exhibits at each pole a small button-like projection, 
which is perfectly transparent. The eggs contain no embryo, 
only finely granular yolk. Embryonic development of the eggs, at 
least in the earlier stages, takes place outside of the body, in damp 
earth and in water. It is very slow, and even in the warm seasons 
occupies four or five months ; in winter far longer. The embryos 
reach the stomach with the food or drinking water. 

The Trichina spiralis is a worm of great importance from a 
pathological standpoint, which makes its sojourn m part in the 
intestinal canal, in part in the muscular system. 

The larva, or muscle trichina, is the form in which the organism, 



ANIMAL PARASITES— PATHOLOGICAL FORMS. 



281 



imbedded in the imperfectly-cooked flesh of hogs, enters the ali- 
mentary system of man. This larva is from Vo. to 1 millimeter 




Trichocephalus dispar. a, male; b, female. (From Mosler.) 

Fig. 102. 






Trichocephalus dispar. A, male; B, posterior extremity of female ; a, head; 6, cephalic 
extremity of body with oesophagus : c, stomach ; d, gut ; e, cloaca; /.seminal canal ; g, penis; 
I, bell-shaped penile sheath, with tip of penis; m, gut of female; n, anus; o, uterus; p, 
vaginal cleft. Magnification, 10. (After Kvichenmeister and Zurn. from Ziegler.) 

in length, and, as a rule, lies compactly curled up within a capsule 
which may contain as many as two, three or five of the larva?. In 



282 EXAMINATION OF THE FECES. 

the hog's flesh, the trichina seems to live without setting up any 
degree of discomfort or reactive myositis, while in man this is 
always very considerable, and the capsules, often even the worms, 
are frequently incrusted with a deposit of lime salts. 

When these embryos enter the stomach of a host, the capsules 
are dissolved, and the intra-enteric development of the larva com- 
mences. This proceeds very rapidly, so much so that within three 
days the worms have, as a rule, reached sexual maturity, and begin 
the process of copulation. Within a week the adult female begins 
to give birth to embryos, and continues to pass them out for sev- 
eral weeks, during which period, it is asserted, between 1,000 and 
2,000 are born. The embryos are supposed to be deposited in the 
chyle vessels in the wall of the intestine, whence they migrate to 
the various muscles of the body, and recommence the cycle. 

The diagnosis may occasionally be made by finding the mature 
intestinal form or embryos in the feces, though this is, indeed, a 
rare occurrence. The adult form measures 3 to 4 mm. in the female, 
and is just appreciable by the naked eye. The male is 1 to 2 mm. 
long, and has two conical projections from the anal extremity. 
The embryo is only 1 mm. or less in length. Eosinophilia is a 
constant accompaniment of the presence of trichina. 

The Cestode Worms. — The cestocles, known popularly as Tape- 
worms, are distinguished both by their external form, and by 
their biological relationship to their hosts from the round worms. 

Externally, they are long, flattened, segmented worms. The first 
member of the segmented series, known also as head and as "sco- 
lex," is specialized in such a manner as to fit it for maintaining 
a hold on the intestinal canal of its host. It has suckers, and, in 
addition, in some species, a circlet of hooks. This head is derived 
from an embryo contained in the ingested flesh of various domes- 
tic animals which are used as food. 

By asexual generation, or budding, it gives rise to all of the suc- 
ceeding segments, the youngest of which is, of course, that nearest 
the head. These successive segments are morphologically exactly 
similar, but diminish in size toward the head. They are known 
as proglottides. The embryo is called a cysticercus. The cestodes 
parasitic in man belong to the families of the Tceniadce and the 
Bothriocephalidw. The former occur in man either as cysticercus 
or as tape-worm ; the latter only as tape-worm. 

Tcenia Solium, a worm which was once very common, owing to 
a custom, formerly more prevalent, of eating raw ham, is now 



AXIMAL PARASITES— PATHOLOGICAL FORMS. 



283 



seldom seen. In Germany, too, tke worm has been well nigh exter- 
minated in certain districts through the Government supervision of 
swine's meat. 

It is a strange fact, however, that the cysticercus form continues 
to occur with disproportionate frequency (Marchand). 

The tape-worm attains a length very often of three meters. The 
head is smaller than the head of a pin. Examined under the 
microscope it appears to be pear-shaped, and is armed with four 
lateral prominent suckers and a circlet, or rostellam, of hooks at 

Fig. 103. 




■Vii. ,.; 



1, Head of Taenia solium; magnification, 50 ; 2,3, Mature and semi-mature segments, 
natural size ; 4, Two proglottides with uterus, twice magnified. (From Ziegler, after 
Leuckart.) 



its crown. These booklets are 26 in number, short and broad, 
and provided with a lateral spur. Below the suckers, the head 
becomes narrowed, and is prolonged into a slender "neck." The 
hooks and suckers serve as organs of fixation whereby the parasite 
anchors itself to the intestinal wall. Below the neck, the imme- 
diate proglottides are narrow and elongated, and gradually become 
broader and less long as they approach the other extremity of the 
worm. The mature proglottides are found at a distance of 100 to 
150 cm. from the head. They are about 10 mm. long and 6 to 7 
broad. Externally, slightly behind the middle of the lateral surface, 
is a papilla which contains the genital orifice or pore. Into this 



284 EXAMINATION OF TEE FECES. 

empty the canals both of the male and female sexual apparatus, for 
each proglottis is hermaphroditic. The male generative organ, or 
"testis," is represented by a number of clear vesicles scattered 
throughout the segment, which unite by means of a system of 
branched canals to empty into the vas deferens. The "ovary" 
consists of a series of interconnecting tubules which form a sort of 
arborization. This again voids to the exterior by the "vagina," 
which opens into the common cloaca at the genital pore. Through 
the middle of the proglottis runs the broad uterus, with many 
branched lateral processes. In this organ the eggs attain their 
development. Laterally lie two canalicular systems, which are a 
means of communication between the successive segments, namely, 
the excretory and the water vascular systems. Externally, the 
proglottis presents a muscular layer of smooth muscle fibers, 
amongst which are interspersed many of the so-called calcium 
corpuscles. 

The eggs may be found in the various segments in all stages, 
from that of the unfertilized ovarian egg to the embryo contained 
in the uterus. The ovarian eggs are light yellow, rounded bodies, 
without a cuticle. 

The progressive development of the egg is marked by the acqui- 
sition of yelk, and of a thick, brownish, chitinous envelope. In 
the uterus segmentation takes place, with the development of an 
embryo possessing a rudimentary scolex with six booklets. In 
this form, the eggs leave the body, and eventually enter the stom- 
ach of their new host, where the cuticular shell is dissolved. The 
embryos then bore their way through the intestinal wall and 
become imbedded as a "cysticercus" in the organs. 

As has been said, the cysticercus is occasionally found in man. 
Taenia saginata, the most frequent form of tape-worm met with in 
America, is found as a cysticercus in so-called "measly beef." 
When this is eaten raw, or insufficiently cooked, the embryo devel- 
ops into a tape-worm in man. 

The cysticercus of Taenia saginata is found in human beings only 
as a very great rarity. 

The worm, when full grown, attains a considerably larger size 
than does T. solium. It measures in length as much as 4 to 7 meters, 
and the proglottides are severally larger and broader than those of 
T. solium, The head has a flat crown, and no rostellum. It is 
armed with four powerful suckers, which have a pigmented border. 
The uterus possesses a vastly greater number of lateral processes 



AXLMAL PARASITES— PATHOLOGICAL FORMS. 



285 



than does that of solium, and they present instead of the terminal 
arborizations seen in the latter form, only dichotomous divisions. 
The sexnal pore is situated on the lateral margin, slightly behind 
the middle of the body. The eggs are indistinguishable from 
those of T. solium., and undergo a similar development. 



Fig. 104. 






Taenia saginata. (Simon.) a, natural size ; 6, much enlarged ; c, ova much enlarged. 

Tcenia cucumerina (see elUptica) is 15 to 20 cm. long. The 
head possesses a rostellum. It occurs in dogs and cats, rarely in 
man. 

The cysticercoid is parasitic in the flea of the dog, rarely in the 



286 



EXAMINATION OF THE FECES. 



pediculi which infest human beings. The cysticercoid occurs in 
cattle. 

Taenia nana (Hymenolepsis nana) occurs not infrequently 
in southern Italy, and rarely in other parts of Europe. In the 
United States attention has been paid to the worm only of late 
years. About 20 cases have been described, the majority of them 
in the Southern States. 

The worm is 8 to 15 mm. in length, and its diminutive size is 
probably responsible for its having so rarely been discovered. It 
occurs in vast numbers, usually located in the lower part of the 
ileum. It has four suckers, and a crown of hooklets. Each seg- 



Fig. 105. 






Taenia cucumerina. 1, head ; 2, mature proglottis; 3, eggs; 4, segments. 



ment possesses three testicles, a generic characteristic. The genital 
pores are situated on the left lateral margin. 

The eggs have two distinct membranes, "the inner one presenting 
at each pole a more or less conspicuous mamillate projection pro- 
vided with filamentous projections." 

The entire life-cycle of this form seems to be followed within the 
intestinal tract of man, the eggs developing in the intestinal villi. 
Infection probably occurs from man to man through the medium 
of hands soiled with infected feces. Infection may persist for 
years. 



AXIMAL PARASITES— PATHOLOGICAL FORMS. 



287 



The diagnosis is most readily made by microscopical examina- 
tion of the stools for eggs. The worms are so minute as generally 
to escape macroscopic detection. 



Fig. 106. 









.Ui- V 


••;.-/.■ 




•,r-°- 


_ 


Sl 




SH 




"Jj-, 




■ 




■.v ~ 




Taenia nana. 1, body; 2, natural size; 3, head; 4, hooklets; 5, eggs; 6, egg, magnified 600 

times. (From Mosler.) 



288 



EXAMINATION OF THE FECES. 



The method recommended by Hallock 1 for finding the worms is 
as follows : 

"The method which so far has proved most satisfactory in find- 
ing the parasites is to dilute the stool with considerable quantity 
of water, and then to run it out in a very thin layer on a large plate 
of window glass having a black background and placed in a strong 
light, the examination being made with a large reading glass. 
The worms appear as very minute translucent or opalescent shreds 
not unlike mucus, and the greatest care is required lest they be 



Fig. 107. 






1, Taenia flavopunctata; 2, head ; 3, mature proglottides ; 4, egg. 
(From Mosler, after Weinland.) 

overlooked. The ova arc found with the microscope much more 
easily than the worms themselves, a two-thirds objective being 
ample after one becomes familiar with their appearance. The 
spread should be very thin, and but little light admitted from 
the condenser." 

Considerable clinical significance attaches to these worms, inas- 
much as in the cases in which they were detected they were respon- 
sible for abdominal and reflex nervous symptoms of some severity. 
Attention has been called to the fact that the undigested portions of 
bananas may simulate small tape-worms. 



Journ. Am. Med. Association, April 2, 1904. 



AXIMAL PARASITES— PATHOLOGICAL FORMS. 



289 



Hymenolepsis (or Taenia) diminuta (or flavo punctata), is a 
tape-worm 20 to 60 mm. in length, which occurs frequently in 
rats and mice, but very rarely in man. The head has no hooklets. 
The cysticercoid is said (Grassi) to inhabit a small butterfly. 

Tcenia Africana (Linston) is a recently-described species found 
in the negroes of Dutch East Africa. 

Tcenia confusa, a new species described by Ward. 

BotJiriocephalus latus (Bremser) is the largest of the 

Fig. 108. 




Middle piece of a proglottis of Bothriocephalic latus, seen from the dorsal surface; the 
external layer almost completely removed ; a, lateral vessels ; b , seminal vesicles; c, seminal 
ducts; d, vas deferens; g, generative glands; h, yolk chambers lying in the cortical layers; 
*, collecting tubules of yolk chambers; I, commencement of uterus; m, coils of the uterus 
filled with eggs ; n, vagina ; o, vaginal opening. 



human tape-worms, reaching a length of 5 to 8 meters, and consist- 
ing of as many as 3,000 to 4,000 short segments. 

The body of the worm differs from that of the taenia previously 
described, in that it tapers towards both extremities. The cen- 
trally-situated segments, which are the largest, measure 3.5 mm. 
in length, 10 to 12 in breadth. The head is ovoid, 25 mm. in length, 
and 1.0 mm. broad, somewhat flattened, and provided on each lat- 
eral aspect with a groove-like sucking apparatus. The uterus is a 
simple, slightly-convoluted canal. The 'sexual openings lie in the 



290 EXAMINATION OF TEE FECES. 

middle line on the ventral surface, the female pore behind the 
male. 

The eggs are ovoid in form, 0.07 mm. in length, 0.045 mm. in 
breadth. They possess a thin, brown capsule, of which the anterior 
pole presents a very distinct and remarkable cap. 

The worm occurs in Switzerland, Holland, northeastern Europe 
and Japan. It is said to occur in America only as an imported 
disease. It may exist as a harmless parasite, or may occasion fatal 
anemias. The plerocercoid inhabits certain fish, the ingestion 
of which frees the embryo which develops into the tape-worm in 
man. In this form it inhabits the small intestine. At long inter- 
vals, segments are passed off in the -stools, generally owing to some 

Fig. 109. 




Fig. 110. 




Free embryo of Bothriocephalus latus, with Eggs of Bothriocephalus latus; the one to 

cilia?. (After Leuckart, from Ziegler.) the right after the discharge of yolk. (After 

Leuckart, from Ziegler.) 



change in diet. The diagnosis may be made by finding these, or 
eggs in the feces. 

Bothriocephalus cordatus is a tape-worm of 80 to 120 cm. 
length. The ripe proglottides measure 7 to 8 mm. in breadth, 3 to 4 
in length. It is rarely found in Greenland and Iceland in man, 
more frequently in dogs. The intermediate host is a fish. 

Dipylidium caninum. This is a very common parasite in dogs 
and cats, and has been found in very rare instances in human 
beings. The parasite belongs to the family Tceniidce, sub-family 
Dipylidiinw. The description, as taken from Stiles, is as follows : 
"Suckers unarmed. Rostellum armed, rarely absent. Genital 
pores lateral, single, or double, and opposite. Genital organs of 
each segment in single or double series. Uterus usually divides 



ANIMAL PARASITES— PATHOLOGICAL FORMS. 291 



Fig. Ill 





1, Adult strobila of Dipylidium caninum (Stiles). 2, Mature segment of same (Stiles). 
3, Gravid segment, c, cirrus (penis) ; c.p., cirrus pouch; ov., ovary ; r.s., receptaculum 
seminis; t, testicle; u, uterus; v, vagina: v.d., vas deferens; v.g., vitellogene gland. (From 
Stiles, after Diamare.) 



292 



EXAMINATION OF THE FECES. 



up into egg sacs, or disappears entirely, so that the eggs lie free in 
the parenchyme. Eggs with thin transparent shells, with or with- 
out appendages. Larvae forms in orthropods or molluscs. Stro- 
bila in mammals, birds and reptiles." The eggs of Dipylidium 
caninum are very characteristic as figured in the illustration. 



Fig. '112. 



Fig. 113. 




Head of Dipylidium caninum, showing 
four rows of rose-thorn hooks and four un- 
armed suckers. (Stiles.) 



1, Egg packet of Dipyliduim. 

2, Egg of same, enlarged. (After Stiles.) 

3, Cryptocystistrichodectis, larval stages 
of Dipylidium, as found in the flea. 
(Stiles, after Leuekart.) 



Fig. 114. 





Eggs of Distoma hepaticum, magnification 200. (From Ziegler, after Leuekart.) 



Other worms of less moment are : 

Trematode Worms. — Of these worms only rare examples have 
been found in the feces, belonging to the species Distoma hepati- 
cum, and Distoma lanceolatum, They are apparently without 
pathological significance. Distoma buskii has been found in 



AXIMAL PARASITES— PATHOLOGICAL FORMS. 



293 



China. Oysters serve as a host. Distoma sibiricum, Distoma 
spatulatum, and Distoma conjunction are other rare trematodes 
occasionally found in man. 



Fig. 115. 




Fig. 116. 





Distoma hepaticum, with male and female 
genital apparatus. (From Ziegler, after 
Leuckart.) 



Distoma lanceolatum. (v. Jaksch.) 



CHAPTEK XVIII. 

CHEMICAL EXAMINATION OF FECES. 

Under the heading of chemical examination of the feces will 
be included those other methods belonging to the physical sciences, 
including spectroscopy, which have for their object d quantitative 
determination of certain conditions. 

A considerable amount of labor has been bestowed on this 
branch of coprology, but not as yet with corresponding practical 
results for the clinician. 

Of most value are the purely qualitative reactions, as for the 
determination of the presence of blood. The feces represent the 
end result of such a complex series of processes that quantitative 
examinations, of the gross kind which we are at present in a posi- 
tion to employ, fail of their object. They give us exact figures, but 
no accurate clinical information. 

Methods. — To a certain extent we can introduce at least one 
positive factor into our calculations from the end result repre- 
sented by the stool. This is offered by the diet. In order to sup- 
ply a constant datum for comparison, Schmidt has suggested the 
following "test diet," which represents a normal mixed diet: 1% 
liters of milk, 3% eggs, gruel from 80 grammes of oatmeal, 100 
grammes zwieback, 20 grammes sugar, 20 grammes butter, 125 
grammes fillet, raw; 190 grammes potatoes, raw; together about 
126.25 grammes of albumin, 83.4 grammes of fat, and 218,5 
grammes of carbohydrates, which are equivalent in all to 2,183 
grammes calories. 

They suggest the following subdivision of this diet : 

6.30 A. M. — % liter milk, 2 zwieback. 

9.30 A. M. — % liter milk, bouillon, with % egg. 

11.00 A. M— % liter milk, 1 egg. 

12.00 M. — % liter oatmeal gruel (from 40 grammes oatmeal, 
166 grammes milk, 10 grammes sugar, and % egg), 100 grammes 
boiled chopped meat (from 125 grammes raw beef and 12 grammes 
of butter), 250 grammes potato puree (from 190 grammes 
mashed potatoes, 60 grammes milk, 8 grammes butter). 

3.30 P. M. — % liter milk, 1 egg, 1 zwieback. 

(294) 



CHEMICAL EXAMINATION OF FECES. 295 

6.30 P. M. — y 2 liter oatmeal gruel. 

This diet may be modified by the omission of the beef and the 
potatoes at noon. 

This diet seems to be well borne by most patients, and may be 
continued for days. If the milk at first sets up a diarrhea, this 
generally subsides within a short time. 

It is often advisable to mark off in some manner the beginning 
and end of the use of some prescribed form of diet in such a way 
as to render its appearance evident in the feces. This is the 
more necessary, inasmuch as the feces, even with daily evacuations, 
does not always contain the remains of the diet of the preceding 
day. Ranke used cranberries for this purpose, but. they are not 
always tolerated by the gut, nor reliable. Rubner used emulsions 
of carbon, which have since been generally adopted (Carbo. veg., 
15.0; mucilage gummi arab., 15.0; ag, menth. pip., 60.0; three 
dessertspoonsful). Patients with -digestive disturbances do not tol- 
erate such large quantities of indigestible material, and in such 
cases it is wiser to substitute carmine for the carbon. Schmidt 
marks off his test-diet by giving at the beginning and the end, 0.3 
grammes of finely-powdered carmine in a wafer. The method is 
not applicable in case one wishes to make the blood test as subse- 
quently described, because the coloring matter of the carmine inter- 
feres with the color reaction. 

It is customary to do chemical examinations on the dried feces. 
The drying may be carried on over a water-bath at low tempera- 
tures. The loss of nitrogen consequent on this method may be 
prevented by the addition of a little sulphuric acid. 

The method of procedure in a chemical analysis is, of course, 
largely dictated by the special object in view. The weight, reac- 
tion, dry residue, are first to be determined. The watery extracts 
contain part of the coloring matters, soluble albuminates, peptones, 
ferments, a few volatile fatty acids, sugar, and part of the salts. 
If the feces are diluted with water and slightly acidified with 
mineral acids, the distillate contains volatile fatty acids, phenol, 
indol, skatol, alcohol, acetone and H 2 S. 

If the acidified feces are extracted first with alcohol and then 
with ether, one obtains the fats (free fatty acid, neutral fats), 
lactic acids, cholesterin, lecithin, blood pigments, biliary pigments, 
sugar, part of the salts, glycosides, chlorophyllan, leucin, tyrosin 
and diamine. 

In the residue remain keratin, elastin, nuclein, cellulose, amy- 
lum, dextrin, gums. 



296 EXAMINATION OF THE FECES. 

Reaction. — The customary manner of making a qualitative test 
of the reaction of the feces is to moisten pieces of red and 
blue litmus paper with distilled, water, and then to touch them with 
particles of the feces. 

A better method, as suggested by Krauss, is to introduce a few 
cc. of a watery solution of litmus tincture (1-10 of water) into 
each of a couple of test-tubes of equal diameter. To one of these 
a small amount of the fecal matter is then added, and the reac- 
tion determined by a comparison of the color. In case the test- 
tubes become clouded through the addition of the feces, this diffi- 
culty may be obviated by centrifugation. 

. The test should always be made on freshly-passed feces, inas- 
much as the reaction may subsequently change quite rapidly to 
alkaline or acid. The entire fecal mass should also be well mixed, 
as it may vary in reaction in different parts, and if it be inspis- 
sated and scybalous, it should be rubbed up with distilled water. 

If one desires to test the reaction with a variety of indicators, 
it is always well to prepare a watery extract with distilled water, 
which is then filtered. In this manner, minute differences in reac- 
tion are occasionally brought to light, owing to the varying sus- 
ceptibility of the indicators. A neutral reaction to litmus may 
be faintly acid to phenolphthalein, and alkaline to cochineal. For 
all clinical purposes, the litmus reaction suffices. 

The quantitative test is made with phenolphthalein as an indi- 
cator, and titration is performed either with one-tenth normal soda, 
or one-tenth normal hydrochloric acid. 

Twenty to fifty grammes of fresh feces are rubbed up with 10 
times their volume of distilled water in a mortar. Titration is 
now performed, and the result controlled either with phenolphtha- 
lein, or by repeatedly testing the reaction with litmus paper. In 
the former case, the reaction is complete when the red color re- 
mains permanent ; in the latter when a light bluish halo surrounds 
the test-drop. The reckoning is then made on a basis of 100 
grammes of feces. 

The reaction of the feces is ordinarily neutral or slightly alka- 
line. If strongly alkaline, the reaction is probably due to an 
excess of ammonia generated by putrefaction of the nitrogenous 
elements. 

If strongly acid, the reaction is determined by the presence of 
free fatty acids, both the volatile and the higher acids. The for- 
mer, with lactic acid, are due to the predominance of carbohydrate 
decomposition, the latter to a superfluous quantity of fat in the 



CHEMICAL EXAMINATION OF FECES. 297 

feces. The fixed alkalies and mineral acids, even though they 
occur in considerable amounts, rarely affect the reaction. The 
excess of alkali in the ash is generally bound by organic acids. 

Thus it becomes evident that carbohydrate fermentation, or the 
splitting of fats, determines an acid reaction, while the putrefac- 
tion of the proteid elements makes for an alkaline reaction in the 
stools. As a rule, the form of diet is, therefore, of significance in 
the final result. 

The feces of nurslings reared on mother's milk is acid. In case 
artificial feeding is used, especially with dilution of the milk, with 
gruels, the reaction is neutral or faintly alkaline. Meat or milk 
diet in adults yields a neutral or alkaline feces. 

The reaction is also influenced by the condition of the digestive 
tract. If bile be lacking, as in closure of the common duct, the 
reaction is acid, owing to decomposition of the fats. Pancreatic 
diseases and disturbances of the absorptive function likewise favor 
decomposition, and determine an acid or alkaline reaction depend- 
ing on the nature of the diet. 

The diagnostic significance of the reaction of the feces is slight. 
In cases of infants an accentuation of the normal acid reaction 
points to fermentation. Acidity occurs in the feces of infants, 
combined with greenish discoloration, and a butyric acid odor, 
in cases of simple dyspepsia, and at the beginning of most acute ill- 
nesses. At the height of these diseases, enteritis, enteritis tuber- 
culosa, tabes mesaraica, typhoid, etc., the reaction is almost invar- 
iably alkaline, and the odor generally ammoniacal. Among adults, 
the value of the reaction is much less limited. 

Dry Residue. — The determination of the dry residue of feces 
affords a scientific measure of the terms diarrhea and constipation. 
Although quantitative determinations have not as yet proved of 
greater diagnostic value than the simple macroscopic estimate, it 
is highly probable that they will play a larger role in the coprology 
of the future. 

The method of arriving at a quantitative estimate of the solid 
contents of feces is simple. The stool is first evaporated to dry- 
ness over a water-bath. This process may be hastened, and the 
evaporation point at the same time lowered by the addition of 
small quantities of alcohol. In order to prevent the evaporation 
of M 3 , which would subsequently effect the quantitative nitro- 
gen determinations, it is customary first to determine the reaction 
of the feces, and if alkaline, to add a small amount of dilute sul- 



298 



EXAMINATION OF TEE FECES. 



phuric acid. If the feces are very rich in fats, drying over a water- 
bath tends to reduce the mass to very adherent clumps, which inter- 
feres with the subsequent process of pulverisation. It is wise, 
therefore, to avoid this difficulty by drying the feces over heated 
sand, the weight of which has been previously ascertained. The 
second step of the process consists in driving off the last rem- 
nants of water by means of the hot-air desiccator. In order to 
accomplish this, the feces must first be pulverized, or, if fatty, 
rubbed up with sand. Desiccation is done at a temperature of 
105° C, until the stools have reached a constant weight. Fatty 
stools must be kept at a lower temperature (97 to 99° C), inas- 
much as the fats would otherwise form an impermeable layer over 
the surface of the fecal mass. To offset the lower temperature, 
the process must be continued over a longer period, even as much 
as two days. 

The details of the entire procedure are as follows: A given 
quantity of fecal matter is weighed, and then dried, first over the 
water-bath, then in hot-air apparatus, until its weight has become 
constant. The final weight, as compared with the first, gives the 
percentage of solid constituents. 

The percentage of solid residue must naturally vary largely 
with the nature of the diet, A meat diet leaves a far smaller resi- 
due of solids than does a vegetable diet. These differences, under 
normal circumstances, may run from 15 to 35 per cent. The residue, 
after various forms of diet under normal conditions, has been 
carefully estimated, and is presented in the following table by 
Schmidt and Strasburper : 



DIET 




DRY RESIDUE 


AUTHOES 


1 


Meconium . . . 






20 
20-40 


Zweifel. 


2. 


Starvation . . . 




Dog 


Zweifel. 


3. 


Milk 




Man 


12-13 


Miiller. 




a. Infants 


■1 


Mother's 

Cow's 


15 
15-25 


Uffelmann. 
Biedert. 




b. Adults . . 


■\ 


With additions . . 


15-20 


Uffelmann. 




Pure 


28 


Uffelmann. 


4. 


Meat ..... 


■1 


Dog 

Man 


34 
29 


Miiller. 
Miiller. 


5. 


Meat and Fat . 






27.5 


Rubner. 


6. 


White bread . . 






25 


Rubner. 




Nudels, etc. 
Black bread . . 






15 
15 
13.4 


Rubner. 


7 




Rubner. 


8 


Potatoes . . . 






Rubner. 


9. 


Peas ...... 






Rubner. 


11. 


Mixed . . . . 






26 


Voit. 



CHEMICAL EXAMINATION OF FECES. 299 

It is not a simple matter to explain the increased amount of 
water in the stools of a vegetable diet. Rubner ascribes it to the 
acidification of the intestinal contents, which tends to inhibit the 
absorption of water. On the other hand, diets, such as meat and 
milk, which have a constipating effect, naturally produce scybalous 
and desiccated feces. There are, of course, other factors which 
even in health influence the amount of water in the stools, e. g., 
deficiency in the amount which is ingested, great loss of fluids 
through sweating, and so forth. 

Conditions of disease both within and without the intestinal 
canal largely influence the consistency of the fecal mass. Con- 
stipation is the most physiological, if it may be so termed, and 
the most constant cause of an alteration of the normal balance. 
The feces become hard, ^and their water may be reduced as low 
as 60 per cent. In diarrheas, on the other hand, the percentage 
of water rises appreciably, as in most diseases of the intestine. In 
cholera, the stools contain 98 to 99 per cent, of water. 

It is essential in making estimates of this kind to employ a defi- 
nite form of diet of which the normal average residue is known. 
With the test-diet of Schmidt, as previously described, the dry 
residue has been found to amount to 24.25 per cent., and to vary 
with pathological conditions, such as dyspepsia and acholia. 

Increased proportion of the solids in the stools is primarily due 
to diminished peristalsis, which, again, is a symptom of a con- 
siderable number of intestinal diseases. Increase of the water 
may be due either to diminished absorption of water, or to 
increased elimination from the wall of the gut. The former is a 
factor chiefly in cases with increased peristaltic action from any 
cause, whether due to the nature of the intestinal contents, 
inflammatory, or nervous. But diminished absorption capacity 
may also be a characteristic of certain diseases of the intestinal 
mucosa, e. g., atrophy, and amyloidosis. Increased exudation or 
transudation of fluid from the intestinal wall occurs in many 
catarrhal and inflammatory conditions, mixed in varying propor- 
tions with pus, blood, or other solid constituents. 

Total Nitrogen. 

In making the test for nitrogen in the feces, the method of 
Kjeldahl, already described in connection with the urine, is em- 
ployed. The nitrates are lost by this method, but are of no account, 
inasmuch as they occur in such small quantities as to be a negli- 
gible factor. The details of the method as applied to the analysis 



300 EXAMINATION OF THE FECES. 

of the feces by Schmidt and Strasburger are as follows : One 
takes two portions, each of 2 to 4 grammes of fresh feces, 
or of 0.5 to 1 gramme of feces which have been dried with the 
addition of sulphuric acid, as previously described. Each of these 
is placed in a Kjeldahl flask, together with 20 cc. of sulphuric acid 
mixture, and one drop of metallic mercury. The so-called sul- 
phuric acid mixture is composed either of three parts of pure 
concentrated plus one part of fuming sulphuric acid, or of 800 cc. 
pure, 200 cc. fuming sulphuric, and 100 grammes of anhydrous 
phosphoric acid. It should contain no free nitrogen. The mercury 
can be washed free of all traces of nitric acid, and is best dropped 
from a capillary pipette. This mixture is well shaken, and set 
aside for twelve to twenty-four hours. The tube is then heated on 
a sand bath for three to four hours, first with a small, then with 
the full flame, until the fluid becomes perfectly clear and transpar- 
ent. The flask is then held in a bowl of cold water, and to its con- 
tents are gradually added 50 cc. of distilled water. The whole 
amount is then poured into a retort, which is cooled by water from 
the hydrant, and to it are added enough soda to alkalinize, and 40 
cc. of potassium sulphate (40 grammes : 11), also a few zinc filings. 

The retort is now connected with the condenser, mid distillation 
begun. The nitrogen bulb into which the ammonia is received 
should contain 40 to 50 cc. (measured) of one-fifth normal solution 
of sulphuric acid. Distillation should be completed in twenty 
minutes, when the cork of the flask is removed, and the distillate 
titrated. This is done with one-fifth normal soda solution, using 
cochineal as an indicator. The calculation is made by multiplying 
by 2.8 the number of cc. of one-fifth normal soda bound by NH 3 ; 
the latter figure is obtained by subtracting from the total number 
of cc. of soda used in titration, the number of cc. of sulphuric acid 
solution previously added to the mixture.. 

The sources of nitrogen in the body are, (1) the secretions and 
other contributions (desquamated cells, etc.) of the body; (2) the 
bacteria and their products; (3) the proteids of the food. The 
first two factors, as has been previously shown, cannot be deter- 
mined with any degree of exactness in health, inasmuch as the 
analysis of the feces in starvation gives figures which can only 
distantly approximate those which maintain under normal condi- 
tions. 

On an average it has been found that "starvation feces" contain 
0.254 grammes of nitrogen. On a nitrogen free diet, Rieder 
found that 0.73 grammes of nitrogen were excreted dailv. This 



CHEMICAL EXAMINATION OF FECES. 301 

shows conclusively that the amount of food influences the amount 
of nitrogen directly contributed by the body to the feces. Rieder 
estimates that this constituent, on a mixed diet, amounts to 29 per 
cent, of the entire amount of nitrogen in the feces. The increase 
in the nitrogen contributed by the body on a full diet is partly 
due to increased secretion, partly to increased desquamation, and 
largely to an increase in the number of bacteria. 

The food determines to a great degree the nitrogen contents of 
the feces. The quality of the food, its quantity, and the thorough- 
ness with which it is digested, are all important factors in the final 
result. As regards the quality, it is a generally valid rule that 
the more "digestible" a food, i. e., the less it leaves of solid residue, 
the less nitrogen does it contribute to the feces. 

To mention only the more important articles of diet, meat, if 
well prepared, eggs, milk, and certain few vegetable foods, such 
as rice, white-bread, nudels, leave little residue, hence little nitro- 
gen, while, on the other hand, a diet rich in vegetable (cellulose) 
constituents, increases the nitrogen content of the feces very consid- 
erably. An important consideration is the fact that the per- 
centage of nitrogen to the entire residue does not necessarily rise 
with the increase of the total nitrogen ; in fact, the reverse main- 
tains. This is an apparent contradiction which is very easily ex- 
plained. The indigestible foods, while they contribute a consid- 
erable amount of undigested proteids to the feces, thus increas- 
ing the total nitrogen, contribute far more, proportionally, of 
other constituents, so that the percentage of nitrogen actually 
sinks, while its total quantity rises. This is well indicated by 
the following tables, taken from Schmidt and Strasburger : 





DIET. 




DAILY NITROGEN. 


PER CENT. OF 








GRAMMES. 


DRY RESIDUE. 


1. 


Macaroni 


6.95 


1.86 


6.88 


2. 


White bread. 


6.89 


1.95 


8.30 


3. 


Rice 


6.38 


2.13 


7.85 


4. 


Maize 


7.50 


2.27 


4.6 


5. 


Potatoes 


307 


3.69 


3.93 


6. 


Brown bread 


13.60 


4.26 


3.68 


7. 


Peas 


6.00 


3.57 


7.35 


8. 


Carrots 


51.33 


2.52 


3.01 


9. 


Mixed vegetables . . . 




3.46 




10. 


Mixed vegetables . . . 




4.01 





It has been calculated in general that under normal conditions a 
diet poor in solid residue yields a feces of which the nitrogen 
amounts to 8 to 9 per cent., with a daily total of 1.14 grammes. 



302 EXAMINATION OF THE FECES. 

On a diet rich in indigestible constituents, the daily nitrogen 
amounts to 2.53 grammes, while its percentage falls to 6.6 per 
cent. As regards the quantity of food, it is a general rule that 
the more there is eaten, the greater the amount of nitrogen passed 
out in the feces. On a diet which leaves little residue, the increase 
is, of course, not so notable. Indeed, up to a certain point, almost 
all of the constituents of such a diet are digested and absorbed. 

Individual variations exist which may considerably modify the 
amounts excreted on a given diet under normal conditions. Simi- 
larly, variations exist owing to exercise, etc. 

Pathological conditions may considerably modify both the 
amount and the percentage of nitrogen excreted in the feces. For 
example, the quota contributed by the intestine itself may fall 
considerably in inanition from any cause. On the other hand, it 
has been suggested that the increase found in such conditions as 
nephritis, leukemia and gout, is due to a heightened excretion 
from the body. All conditions which interfere with the proper 
digestion of the food increase the total nitrogen, although they 
tend to decrease its percentage, in the manner previously indicated. 
Gastric diseases have very little influence in this direction, inas- 
much as the functions of the stomach are vicariously assumed by 
the intestines. Biliary obstruction interferes only to a very slight 
extent with the digestion of the proteids. Failure of the pancre- 
atic secretion, however, may increase the fecal nitrogen enor- 
mously, leading to what the French authors describe as azotorrhea. 

The other forms of intestinal disease are so complex, that it 
is, as a rule, impossible to determine whether the increase of nitro- 
gen in the feces be due to deficiency of secretion or absorption, or 
to increased peristalsis. 

Those conditions which are associated with the loss of blood or 
pus naturally cause an increase in the nitrogen total and per- 
centage. Amyloid and tabes mesaraica increase the nitrogen 
through failure of absorption. 

The most valuable diagnostic hint to be derived from these quan- 
titative examinations has been elucidated by Weintraud. He 
finds that in pancreatic disease the loss of nitrogenous constituents 
is far greater than that of fats, a condition which does not main- 
tain in diseases which interfere only with absorption, e. g., amy- 
loid. 

Another method has been described for the determination of 
the proteid residue in the stool, which has not as yet been thor- 
oughly tested, but bids fair to displace that of Kjeldahl. It was 



CHEMICAL EXAMINATION OF FECES. 303 

worked out by Koziczkowsky in Senator's clinic, on the basis of a 
similar method previously used by Meunier and Volhard. Essen- 
tially, Koziczkowsky mixes a definite amount of prepared feces 
with a mixture of HC1 and pepsin solution, of which the HC1 con- 
tent is definitely known. This mixture is kept in the incubator for 
twenty-four hours, after which he determines by titration how 
much of the free HC1 has become bound. 

For general diagnostic purposes, it is well to combine the test 
with the use of a test-diet. Either that previously described, or the 
following modification, as suggested by Philippsohn, and accepted 
by Straus, may be used : 

First breakfast, — }/ 2 liter milk, 2 zwieback. 

Second breakfast. — 14 liter bouillon, 1 egg, 1 zwieback. 

Noon. — Gruel (*4 liter milk, 1 egg, 20 grammes of oatmeal, 
and water), 80 grammes scraped beef (boiled with 20 grammes of 
butter), 200 grammes potato puree.. 

Afternoon meal. — % liter milk, 1 zwieback. 

Evening. — Gruel as at noon (without an egg), 2 zwieback, 20 
grammes of butter. 

The total amounts to: 1V 2 liters of milk, % liter of bouillon, 6 
zwieback, 40 grammes of oatmeal, 40 grammes of butter, 2 eggs, 
80 grammes scraped beef, 200 grammes of potato puree. This 
diet is marked off by carmine or carbon. In making the test, its 
author used two portions of stool, each equivalent in dry residue to 
two grammes. These portions were well rubbed up with alcohol, 
poured into a nitrogen-free filter, washed with absolute alcohol, 
and then treated in the following fashion : One portion was mixed 
with 50 cc. of a digestive fluid composed of 1,000 cc. of aqua 
destillata, HC1 (1.19) 10.0, and pepsin 30. The second was 
mixed with the identical amount of the same mixture after previ- 
ously rendering it apeptic by cooking three-quarters of an hour in 
steam. The acidity of both mixtures was then determined, and 
also their peptonizing strength, by means of Mette's tubes. After 
twenty-four hours in the incubator, the content of both bottles was 
filtered, and the amount of free and of combined HC1 determined 
by titration with one-tenth normal soda solution, using dimethyl- 
amidoazobenzol and phenolphthalein as indicators. 

Considerable labor has been devoted to the differential esti- 
mation of the soluble albumins, albumoses and peptones, and of 
the casein in the stool, but this is of so little practical and diag- 
nostic importance, and is in itself so difficult, that it had best be 
neglected. 



304 EXAMINATION OF THE FECES. 

Mucin. — The chemical examination of the feces for mucin is 
for practical purposes of far less import than the macroscopic or 
microscopical tests. Of the earlier methods, that of Hoppe-Seyler, 
which is generally described in the text-books, is unreliable. 

In this method, the feces are rubbed up with water, and then an 
equal quantity of milk of lime is added. After this mixture has 
stood for several hours, it is filtered, and the filtrate tested with 
acetic acid. Clouding of the acid is taken as evidence of the pres- 
ence of mucin. Unfortunately, the method, as has been shown by 
Gatzky, is far better adapted to reveal the presence of nucleins and 
nucleo-albumins than of mucin. 

The great difficulty with the chemical demonstration of mucin is 
the fact that mucus secreted in the upper part of the gut is so 
altered during its passage as to lose its character, while that 
formed low down in the colon is so dense, and is so permeated by 
fats and cells, that it is almost insoluble. There is at present, 
indeed, no satisfactory method for the demonstration of mucin 
in the feces. Least of all should one expect this with the mucin in 
solution, as that has almost certainly lost its original properties. 
Carbohydrates. — Sugar. — The quantitative tests for sugar in 
the feces, as in urine, are the classical reactions — Trommer's, 
JNTylander's, and the phenyl-hydrazin test. It never occurs nor- 
mally in adults, and in healthy infants only in minute traces. It 
is said that dyspeptic and diarrheal conditions in infants are asso- 
ciated with the presence of greater quantities of sugar in the feces. 
Starch. — The qualitative determination of starch is most simply 
made by means of a microscopical examination. In most cases this 
suffices, but in some it gives a negative result when the macro- 
chemical reaction is positive. The former test consists, as previ- 
ously described, in adding Gram's solution to the slide preparation 
under the microscope. In the latter test, the feces are boiled with 
water, and filtered. The filtrate may be somewhat concentrated 
by treating over the water-bath, and to it is added a solution of 
iodine and iodide of potassium in water. The characteristic blue, 
or bluish-red reaction (erythrodextrin) results. 

A variety of quantitative tests have been described, and have 
been in use, but the best is that described in 1898 by Ad. Schmidt. 
The patient is placed on test-diet, No. 2, as already detailed. In 
making the test, it is customary to use five grammes of feces of 
moderate consistency, using more if the stools are very soft in 
consistency, and less if hard. The feces are then thoroughly mixed 
with water and placed in the bottle designated a a" on the figure. 



CHEMICAL EXAMINATION OF FECES. 305 

Into tube "b" water is poured. Both "a" and "b" should be quite 
full, and it is essential for the accuracy of the result that they 
contain absolutely no air. The apparatus is then adjusted, as 
shown by Schmidt. Tube u c" has a minute aperture at the tip. 
The entire apparatus is placed in the incubator at 37° for twenty- 
four hours, during which time water in "b" is displaced by the 
gas which is formed in "a." The water displaced is driven into 
"c," and by its quantity affords a measure of the amount of carbo- 
hydrates in the feces. A notion of the actual amount of starch 
represented by the water displacement is deducible from the fact 
that the addition of 0.1 gramme of starch to normal feces causes 
"c," which holds about 30 cc. to be half -filled during the test. Neg- 
ative results, especially in stools not apparently normal, cannot be 
taken to indicate the absence of starch, as in abnormal stools the 
process of fermentation is interfered with. It is important to 
exclude nitrogenous fermentation, which is done by controlling the 
reaction with litmus. Carbohydrate fermentation gives an acid 
reaction, even if slight ; nitrogeneous, an alkaline. 

The diagnostic value of this test may be considerable, inas- 
much as the digestion of starches suffers notably in certain func- 
tional and organic diseases of the intestine. Disturbances in 
the small gut particularly affect the starch digestion. They 
are generally, but by no means invariably, associated with diar- 
rhea, the so-called "fermentative diarrheas." Gastric conditions 
do not affect the digestion of starches. Biliary obstruction also, 
although it results in the production of feces rich in fats, does not 
interfere with amylolysis. Diseases of the pancreas appear in 
some cases to exercise a marked inhibitory effect on starch diges- 
tion, in others not. 

Hydrobilirubin. — There are a number of tests for the presence 
of hydrobilirubin, of which the best known are the following : 

1. Schmidt's sublimate test. — Fresh feces are requisite. A 
piece as large as a hazel or walnut is rubbed up in a mortar with 
a small amount of concentrated aqueous solution of sublimate, and 
the mixture is then allowed to stand in a covered watch-glass several 
hours. The hydrobilirubin is then colored red, the bilirubin green. 

Fleischer s test. — A small amount of fecal matter is treated with 
acid alcohol in a test tube. When the alcohol takes on a brownish 
color, it is poured off, and a few drops of ammonia are added to it. 
In the presence of hydrobilirubin the fluid takes on a transparent 
red color, with greenish fluorescence. The spectroscopic test. — A 
characteristic absorption band between b and F, nearer F. 



306 EXAMINATION OF THE FECES. 

Bilirubin. — 1. The sublimate test. 

2. Gmelins reaction, — To nitric acid in a watch-glass is added 
drop by drop the fecal matter mixed with water, when the charac- 
teristic play of colors ensue. 

Fat. — The qualitative demonstration of fat in the feces by chem- 
ical means is a very simple matter. The feces are extracted with 
ether, and the latter allowed to evaporate on filter paper, where it 
deposits a film of fat. The microscopical examination is, however, 
equally conclusive. The quantitative estimation is of far greater 
moment, especially the differentiation of the three constituents 
usually grouped together, viz. : neutral fats, fatty acids and soaps. 
In certain diseases, this estimation is of very great importance, yet 
practically the tests are so imperfect and so complicated as to be 
unavailable for diagnostic purposes. The simplest method is ex- 
traction with ether. The test-diet, as previously described, is 
made use of, and 5 grammes of moderately firm feces (more, if 
less firm, less if inspissated), are extracted for three days with 
ether. The extract is then withdrawn, the fat removed by evap- 
oration, and weighed. 1 Another method is the extraction by 
chloroform (Rosenfeld). Liebermann and Szekely 2 have sug- 
gested a saponification method. 

Fats, like proteids, are derived both from the body and from the 
food, and are subject to the same variations as described under that 
heading, from changes in the quality and quantity of the food, and 
other causes. Under normal conditions, however, the fats never 
amount to more than 20 per cent, of the feces, on an average, 7 
to 8 grammes a day on a mixed diet. Under pathological condi- 
tions, the fats may reach 80 to 90 per cent, of the feces. The con- 
ditions which influence fat digestion and absorption are numer- 
ous, but those which are really diagnosticible as such from the 
stools are limited in number. Gastric conditions play a very small 
role, if any, in determining the fat elimination. The existence of 
a fat-splitting ferment in the stomach, as recently determined, 
might lead one to expect that achylia would perhaps result in a 
partial failure of fat digestion. This does not, however, appear to 
be the case. The most notable changes in fat elimination occur 
with biliary obstruction. In Fr. Muller's investigations, it was 
found that with complete biliary obstruction the feces contained 
49.1 per cent, of fat instead of about 20 to 25 per cent., as in nor- 
mal conditions. The effects of pancreatic obstruction on the 

1 Centralblatt f. inaere Medicin, 1900, No. 33. 

2 Pfliiger's Archiv, 1898, p. 360. 



CHEMICAL EXAMINATION OF FECES. 307 

absorption of fats are unfortunately not as yet fully determined, 
owing to the divergent reports of recent writers on the subject. 
On the whole, both clinical observation and animal experimenta- 
tion seem to indicate that pancreatic obstruction causes a notable 
decrease in fat digestion and absorption. If, however, the fat of 
the food be in the shape of an emulsion, e. g., in milk, the deficiency 
is far less marked. Other pathological conditions, such as enteric 
catarrhs, heart disease, with congestion of the viscera, tabes 
mesaraica, and amyloidosis may all result in deficiency of fat diges- 
tion and absorption, to such an extent that as much as four times 
the normal amount of fat is thrown out in the feces. A very im- 
portant factor in the diagnosis of pancreatic obstruction is offered 
by the relative amounts of neutral fats, on the one hand, and of 
soaps and fatty acids, On the other, in the stools. Whereas in the 
feces of adults three-quarters of the fats are split up under normal 
conditions, in pancreatic disease only one-third to one-fifth are 
found as soaps and acids, the rest as neutral fats. If, however, the 
fats of the diet are taken in largely in emulsified form, this differ- 
ence is very largely lost, inasmuch as the fat-splitting ferment of 
the stomach is then capable of replacing to a very considerable 
extent the function of the pancreatic juice. 

The diagnostic application of fat determinations in the feces is 
unfortunately very greatly hampered by the difficulties and com- 
plexities of the quantitative methods. The use of a definitely 
measured test-diet, the quantitative determination of the total res- 
idue, and of the total fats, are very laborious procedures. On the 
other hand, a simple microscopic, or even macroscopic, examina- 
tion, often suffices to reveal variations of any magnitude from the 
normal. The diagnostic significance of fat in the stools is sum- 
marized as follows by Schmidt and Strasburger : In biliary stasis, 
the fats are very largely increased in the stools, but fat-splitting 
is unaffected, and proteid digestion is normal. In disease of the 
absorptive functions (amyloid, tabes mesaraica) both proteid and 
fat digestion suffer, the latter, however, in greater degree. Pancre- 
atic disease induces, under certain circumstances, as previously 
described, very considerable changes in fat digestion, notably in 
the fermentation of fats, as well as in proteid digestion. 

Blood. — Within very recent years, the detection of blood in the 
feces has become of greater diagnostic importance than had been 
previously thought to be the case, and concomitant with this dis- 
covery there has been some refinement in the methods of the labora- 
tory. 



308 EXAMINATION OF THE FECES. 

It was first pointed out by Boas that blood in the stools might not 
only be an indication of intestinal disease, notably new .growths, 
but that it might in many cases afford the only diagnostic evidence 
of cancer of the stomach. In these cases, however, it is apt to occur 
in very minute amounts, latent traces, so that much care and 
refinement of technique is necessary to demonstrate it with cer- 
tainty. 

The older tests for blood are the Teichmann test for hemin, and 
the turpentine-guaiac test of Schonbein and Almen. 

The Teichmann test is performed as follows: A suspected por- 
tion of stool is rubbed up with a small quantity of water and acetic 
acid and then filtered through a piece of cheese-cloth. The filtered 
material is then precipitated by boiling after alkalinization with 
sodium hydrate, and the precipitate tested for hemin. A small 
particle of it is brought on a slide, together with a few crystals of 
common salt and a drop of glacial acetic acid, and then slowly 
brought to the steaming point and kept there for about one minute. 
As the acetic evaporates, fresh acid is added. If hemin be present, 
the fluid takes on a brownish tinge. It is allowed to cool, and is 
then examined microscopically. AVhen the test is positive, one 
finds the so-called hemin crystals, which are hematin chloride. 
The test is extremely delicate, but very often fails in spite of the 
presence of blood in the feces. In order to insure its success, both 
the heating and the cooling should take place very slowly. The 
reaction also occurs at ordinary room temperatures, if the blood, 
common salt and acetic be allowed to stand for twenty-four hours, 
covered by a cover-slip. Of greater practical value, and more com- 
monly used, is the turpentine-guaiac method which has been espe- 
cially modified to suit the conditions which are found in the feces. 
It is advisable first to remove the fats from the stool, inasmuch 
as they interfere with the reaction. This is done by extraction 
with ether. In case the amount of fat is very considerable, it is 
wise first to dry out the feces over a water-bath. As a rule, how- 
ever, the fresh feces may be extracted. Extraction is performed by 
repeatedly rubbing up a given portion of feces with ether, or by 
shaking the mixture in a wide-mouthed flask, and renewing the 
ether several times. 

Another difficulty peculiar to the application of this test to the 
feces or the stomach contents, is the fact, first pointed out by 
Weber, that the characteristic blue reaction may be induced not 
only by blood, but by potatoes and other vegetable constituents, also 
by bile, milk, pus, and other occasional constituents of feces. 



CHEMICAL EXAMINATION OF FECES. 309 

It is, therefore, advisable to carry out the test not on the feces, 
but on an acetic acid extract of them, prepared as follows, accord- 
ing to Weber: A portion of the feces is rubbed up with water, to 
which one-third of its volume of acetic acid has been added, and 
the mixture is then extracted with ether. After the mixture has 
cleared up, a process which may be hastened by the addition of 
some alcohol, the ether is poured off, and to it are added 10 drops 
of tincture of guaiac, and 20 to 30 drops of old French oil of tur- 
pentine. In the presence of blood, this mixture takes on a bluish- 
violet tinge. In the absence of blood, it becomes reddish-brown, 
often with an admixture of grayish-green. The blue coloring mat- 
ter may be brought out more sharply by adding water and then 
extracting with chloroform. In making this test, it is very impor- 
tant that the turpentine should be ozonized, as are the old oils. 
Unless one is sure of its quality, it is best to make a preliminary 
test of it on a very dilute watery solution of blood. Of late years, 
considerable doubt has been thrown on the validity of this method 
for the examination of the feces ( Schmilinsky, Koziczkowsky), 
although it is generally admitted to be a satisfactory test for blood 
in the stomach contents. 

If there is a considerable amount of blood in the stool, the blue 
reaction is quite marked, and distinct, but in case of small, or 
minimal quantities, the terminal reaction may be marked by a 
green, brown, or brownish-red, coloration, owing to the obscuration 
of the primary blue color by the pigment matters of the feces, e. g., 
urobilin and its derivatives. Such a reaction is, of course, inde- 
cisive, and the method is, therefore, at fault in just these cases 
(carcinoma of the stomach) in which its service would be of 
supreme importance. 

Klunge and Schaer suggested that the test might be made much 
more delicate by the substitution of a watery solution of Barba- 
does aloin for the guaiac, and their contention has been confirmed 
by an elaborate research carried on in Senator's clinic by Kozicz- 
kowsky. 1 

He found that the test reacted to such quantities as 0.025 
grammes in 2 grammes of stool. With a test of such extreme deli- 
cacy, however, it is necessary to exclude all foods containing 
blood from the diet, and also to restrict the chlorophyll. A 
patient in whom there is a suspicion of occult gastric or intestinal 
hemorrhage, or whose stools have previously given a positive reac- 
tion, should be put on a preliminary diet of milk, bread, eggs, 

1 Deutsche med. Wochenschrift, 1904, p. 1198. 



310 EXAMINATION OF THE FECES. 

fruits and starchy foods. The fats should be restricted, as should 
also the vegetables, on account of their chlorophyll. This diet is 
initiated by a dose of carbon (not carmine), which serves to deter- 
mine the time when the constituents of the previous diet have 
passed out of the bowel. When the carbon has once made its 
appearance, the test should be made on the feces on several suc- 
cessive days. A given portion of feces is selected and rubbed up 
with 10 times its volume of alcohol, in order to remove as much 
urobilin as possible, inasmuch as its color may obscure the test. 
The alcohol is then removed by filtration. The fat is then ex- 
tracted with ether, as previously described. The blood is then to 
be digested out with glacial acetic, and extracted with ether. It is 
important to use enough of the former, and not too much of 
the latter, say 5 grammes of feces, 5 grammes of acid, and 5 to 
10 ccm. of ether. If necessary, the acetic acid-ether extract is then 
filtered clear. This extract is layered over with 1 to iy 2 ccm. of 
ozonized oil of turpentine, and to them are added about 7 to 10 
drops of a 3 per cent, solution of aloin. The latter should always 
be freshly prepared, by dissolving 0.3 grammes of aloin powder in 
10 cc. of 60 to 70 per cent, alcohol. The reaction is to be per- 
formed in a conical test-tube, e. g., a centrifuge tube. 

When the test is performed in this manner, the reaction may 
occur in one of three -ways : 

1. The turpentine forms a distinct layer over the ether ic extract, 
and at the junction of the two fluids is seen a very distinct, trans- 
parent, reddish ring. 

2. The reagents become intimately mixed, and a diffuse reddish 
coloration results. 

3. The turpentine sinks to the bottom, and the red layer is 
found at the bottom, or tip, of the test-tube. The reddish ring in 
cases , 1 and 3 fades gradually into a reddish discoloration of the 
neighboring fluid. When the tube is shaken there occurs a diffuse 
reddish discoloration of the entire liquid. The reaction may occur 
at once, or only after standing for three to five minutes. If fat 
has passed over into the etheric extract, it is well to add consider- 
ably more turpentine, as it is reduced by the fat. 

When the reaction is positive, especially when it has proved so 
repeatedly, under the prescribed dietetic precautions, it may be 
positively concluded that there is blood in the feces. 

The diagnostic significance of this fact must, of course, be con- 
trolled by the clinical findings. Hemorrhages from the nose, 
mouth, pharynx, stomach, intestines, from polyps, or hemorrhoids, 



CHEMICAL EXAMINATION OF FECES. 311 

are, of course, alike capable of giving rise to a positive reac- 
tion. 

Koziczkowsky, who is authority for the major part of what has 
been written on this subject, finds that carcinoma of the gastro- 
intestinal tract in a series of tests give an almost invariably positive 
reaction. The same cannot be said of ulcers. The presence of 
blood in the latter is only occasional and intermittent. Its occur- 
rence seems to coincide with the exacerbations of the disease, as 
denoted clinically by increase of the pain, or vomiting. 

The test affords a certain way out of the complexities and diffi- 
culties which often beset the physician in the differential diagnosis 
between organic gastric disease on the one hand, and cholelithiasis, 
hyperchlorhydria, nervous gastritis, and benign obstruction of the 
pylorus on the other. 

In making the diagnosis on the strength of these findings, it is, 
however, essential to exclude any cause of hemorrhage below the 
stomach. The value of the test in cases of intestinal disease is also 
considerable, especially as clearing up obscure cases of constipa- 
tion or partial obstruction. Portal or cardiac venous obstruction, 
with their occasional hemorrhages into the bowel, should, of 
course, be excluded. 

In addition to the chemical tests as previously described, the 
feces may be spectroscopically examined for the presence of blood, 
or of any one of the numerous derivatives of blood pigment. Inas- 
much as the spectrum is apt to be obscured in the feces, even in 
the presence of considerable quantities of blood, by the normal 
pigments in the feces, it is necessary in some way to get rid of 
these. A further difficulty is the fact that hematin is very im- 
perfectly soluble in water. 

To obviate these objections, Sahli recommends the following 
procedure: A few cubic centimeters of the feces are mixed with 
water, and sulphuric acid is added drop by drop until the congo 
reaction is obtained. This mixture is then filtered, and the filtrate 
extracted with ether. If the ether does not separate properly, a few 
drops of alcohol may be added. When blood is present, the ether 
takes on a reddish-brown coloration, and gives the characteristic 
spectroscopic line of acid hematin in the red. The clinically im- 
portant spectra are shown in the diagram. Oxyhemoglobin gives 
two absorption bands, lying between the Traunhofer lines D and 
E. The band which lies nearest the red end of the spectrum is 
narrower, darker, and more clearly defined than the other. The 
former is known as the "a-band," the latter as the "B-band." The 



312 EXAMINATION OF THE FECES. 

character of the bands is not constant, in all cases, but varies both 
as to distinctness and breadth, with concentration of the solution of 
oxyhemoglobin and with the width of the stratum of liquid 
through which the light passes. If the solution be made extremely 
dilute, the "B-band" is lost, and the "a-band" becomes extremely 
faint. With such minimal amounts the chemical examination 
gives more positive and reliable results. With very strong solu- 
tions, the bands fuse. Solutions of reduced hemoglobin show only 
one band, the "g-band," which also lies between D and E. It is 
very diffuse, and also varies with the strength of the solution. 
Methemoglobin is a compound in which the oxygen is held in more 
stable combination. Its spectrum gives two bands between D and 
E, and one between C and I). Hematin is obtained through the 
decomposition of hemoglobin by acids or alkalis in the presence 
of oxygen. It also has a characteristic spectrum, as shown in the 
diagram. 



CHAPTER XIX. 

CHARACTERISTIC PICTURES IN DISEASE. 

Acute Enteric Catarrh. — In acute enteritis the diagnosis depends 
in greater part on an examination of the stools, which also affords 
the most exact indication of the actual seat of the process. 

The feces are of a diarrheal consistency, fluid and frequent. 
There may be as many as 10 to 15 passages a day, rarely more, the 
frequency depending largely on the degree of involvement of the 
large intestine, especially the transverse and descending colon. 
Indeed, isolated catarrh of the small bowel may run its course with- 
out giving rise to diarrhea. At the onset the stools are semi-solid, 
but rapidly become fluid; even at the height of the disease, how- 
ever, there may be an occasional well-formed movement. 

The stools, when characteristic, are almost watery, and often 
associated with much foul-smelling gas. The amount of gas and 
the odor are, however, largely dependent on the nature of the diet 
and the localization of the catarrhal process. Thus carbohydrates 
are split up into marsh-gas and certain organic acids, and lend a 
peculiar odor, and a more acid reaction to the stool. A milk diet 
gives the odor of butyric acid, and also tends to modify the reaction. 

If, however, the catarrh is limited to the colon, these decomposi- 
tion processes do not go on, and the food is normally digested and 
absorbed in the small intestine. The character of the stool is then 
largely determined by the exudates from the wall of the gut. 

The color of the dejections varies from a light golden brown to 
a darker brown than is seen even in normal feces. These variations 
depend on the degree of oxidation of the biliary pigments, and 
afford a very valuable indication of the seat of the catarrh. If 
bilirubin appears in large amounts, giving rise to a yellowish dis- 
coloration of the stool, it is always an evidence that the small bowel 
participates in the affection, and that its contents are hurried 
through so rapidly that the pigments do not become reduced as 
normally to urobilin. In children the stools may even be green, 
from biliverdin, but in adults this is rarely the case. Where biliv- 
erdin or bilirubin are present, it is generally possible, in case of 
the former, always, to obtain the typical Gmelin reaction. 

When there is a very profuse serous diarrhea, especially in 

(313) 



31-1 EXAMINATION OF THE FECES. 

colitis, the dejections are often perfectly colorless. This condi- 
tion is, however, far more frequently found in some of the specific 
enteric inflammations, e. g.. cholera. 

Mucus is practically never absent, and affords valuable hints as 
to the severity and the localization of the process. It may be inti- 
mately commingled with the more or less fluid mass, lending to it 
a jelly-like consistency, or it may merely coat the exterior of the 
fecal masses in more or less voluminous clumps. The former con- 
dition maintains in catarrhs of the small intestine, the latter in 
colitis. Rarely in acute proctitis, or inflammation of the lower 
colon, are solid masses of pure mucus expelled. The mucus is 
often colored with bile pigment, bilirubin or urobilin, which gives 
further evidence of its origin. It may be clear, hyaline, and 
transparent, or turbid and opaque. The latter condition is often 
falsely described as muco-purulent. Microscopical examination, 
however, reveals the fact that there is an admixture not of pus, 
but of desquamated epithelia. The latter may be fairly well pre- 
served if derived from the large gut, but if coming from higher 
portions of the intestine are often entirely disintegrated and 
fragmented. Pus cells are an extremely rare finding in the stools 
in cases of pure inflammation. Blood is never found. 

The constituents of the diet may appear in more or less unal- 
tered form. This is especially the case when the small intestine 
is involved, with increase of its peristaltic action, and decrease in 
its digestive and resorptive capacity. The continued observation 
of the stools may serve to discover the irritant cause of the catarrh, 
in the shape of undigested particles of some kind of food, eaten, 
perhaps, two or three days -previous to its passage. The event 
ordinarily denotes the beginning of a recovery. The chemical 
examination of the stool in this condition offers little of service. 
The bacteriological examination is important only in the specific 
inflammations. 

Chronic inflammations of the intestine play a very important role 
in intestinal medicine — a role which is none the less impor- 
tant for being rather more limited than is generally supposed. The 
diagnosis of chronic catarrh is very frequently made in cases of 
diarrhea or of constipation from a large number of other causes,- 
such as muscular atony, or spasm, or vascular disturbances, or 
certain organic diseases of the bowel. These latter conditions may 
all be easily and accurately distinguished from true catarrhs by 
the character of the stools. Their consistency varies with the 
degree of activity of the intestinal peristalsis — in cases of diarrhea, 
thin or semi-fluid ; in cases of constipation, even scybalous. 



CHARACTERISTIC PICTURES IN DISEASE. 315 

The chief characteristic of importance is the presence of 
mucus, which, as detailed in the general section, is an almost 
invariable evidence of catarrhal inflammation. Rotable excep- 
tions are the cases of enteritis membranacea, and of the physiologi- 
cal mucoid excretion from the rectum- and the colon which accom- 
pany many cases of constipation. Mucoid catarrhs are not nec- 
essarily primary, but may accompany cancer or ulcer. On the 
other hand, absence of mucus is almost invariably evidence of the 
absence of a chronic inflammatory process in the intestine. The 
amount of mucus varies enormously, as detailed in the general 
sections. The stool may consist of small portions of mucus com- 
mingled with fecal products, or there may be practically nothing 
except mucus in the dejections. As in acute inflammations, there 
is neither blood nor pus in the simple catarrhs ; but epithelial 
cells are present in abundance. 

The other characteristics of the 'feces, color, odor, reaction and 
composition vary in the same degree, and from the same causes, 
as in cases of acute inflammations. What has been said under that 
head may be accepted here also. 

The frequency of the stool varies greatly in chronic catarrhal 
processes. Most characteristic are alternating periods of diarrhea 
and constipation, the periods lasting either days, weeks, or even 
months. Rarer are continuous constipation or diarrheas. 

Purulent Enteritis (Enteritis phlegm onosa vel purulenta). — This 
very rare condition has not been coprologically studied. 

Diphtheritic Enteritis ( Enteritis diphtheritica vel crouposa. — 
There is always diarrhea, often with tenesmus. The stools are 
fluid, with occasionally the passage of formed feces. They con- 
sist chiefly of pus, blood, and mucus. If food is being taken, this 
is generally mingled in more or less altered condition with the 
fluid exudate. Sometimes careful search will reveal the presence 
of macroscopic particles of tissue derived from the wall of the gut. 
They are, however, generally so altered and necrotic as hardly to 
be recognizable microscopically. Diphtheritic enteritis, as it 
occurs in cachetic individuals, c. g., in tuberculosis, carcinoma, etc., 
is often associated with amyloidosis of the intestinal wall. This 
results in extremely thin, fluid stools, in which large numbers of 
pus cells are contained, a condition characterized as blenorrhea 
intestinalis. 

Muco-membranous Colitis (Colica mucosa et enteritis membran- 
acea). — This disease is, as a rule, not associated with fre- 
quency of stool. Indeed, the reverse is rather the case. The 



316 EXAMINATION OF THE FECES. 

dejecta are characteristically composed in greater part, or exclu- 
sively, of mucus. This mucus has a tough, leathery consistency, 
which lends it the capacity to assume and retain certain definite 
shapes, usually representing a ca.st of the gut. In this regard, the 
mucus resembles that produced in certain forms of bronchitis. In 
shape, it is most frequently tubular, or tape-like, and may present 
elevations and depressions which are taken to represent casts of the 
tamiae and haustra. In color, they are either transparent, or 
grayish and semi-opaque. They may be stained brown by the 
admixture of fecal matter, or red (Xothnagel) by blood. The 
shapes taken by these mucoid masses vary greatly. They occur not 
only in the typical forms described above, but as clumps, or as 
dendritiform masses, or as reticula. As a rule, when immersed in 
water, these various shapes resolve them into the fundamental form 
of membranes. At first sight, they are mimicked by various other 
elements which are apt to appear in the feces — fascia, undigested 
tendon, arteries and veins, orange peelings, curds of milk, or even 
bacterial conglomerates, such as Leptofhrix. 

Microscopically, the masses are found to consist of mucus, 
which is typical in its appearance and reactions. In addition, epi- 
thelial cells are invariably found, often in enormous amount, fre- 
quently well preserved, and again in various degrees of degenera- 
tion and alteration. Leucocytes are rare or missing. Eosinophiles, 
as has previously been stated, are not rarely a concomitant of the 
condition, in the same manner, possibly, as they are found in cases 
of bronchial asthma. The chemical analysis of the material 
voided in this disease reveals in the vast majority of cases that it 
is composed almost exclusively of mucin. With this are mingled 
traces of albuminoid substances, globulin or nucleo-albumin, which 
may, in exceptional cases, even exceed the mucin in amount. 
Fibrin occurs not at all, or only in traces, the statements of many 
observers to the contrary notwithstanding. 

Ulcers of the Intestine. — The examination of the feces plays a 
most important part in the diagnosis of ulcers of the intestine. 
As regards frequency of stool, in cases of ulcer, this may vary 
enormously. It appears that there may be very numerous and 
extensive ulcerations of certain parts of the tract without any 
consequent diarrhea. Thus the small intestine, the cecum, and 
the ascending colon may be found at autopsy to contain ulcera- 
tions, perhaps even very extensive, yet during life there has been 
normal frequency of defecation or even constipation. A notable 
example of this condition is presented by many cases of typhoid, 



CHARACTERISTIC PICTURES IX DISEASE. 317 

which run their course throughout without diarrhea. Xothnagel 
says, it is very probable that the diarrheas which do occur in 
some typhoids must be attributed, as suggested by Cohnheim, in no- 
wise to the ulcerations, but to the irritant action of the typhoid 
poisons on the gut. Ulcerations of the transverse find descending 
colon, of the sigmoid loop, and of the rectum especially, almost in- 
variably set up diarrhea, however. Exceptions have been recorded 
to this rule, as in a case of a phthisica of Kortum's, in whom the 
descending colon was riddled with tuberculous ulcers, yet there had 
been only one stool daily. It is possible in such apparent excep- 
tions that the nerve endings in the wall of the gait are destroyed 
by the ulcerations or paralyzed by the toxins. The stools are, as a 
rule, rather softer than usual, or even fluid. Here again, the lower 
the seat of the ulceration, the more characteristic is this symptom. 
In cases of ileal or jejunal ulcerations, the feces may have quite a 
normal consistency. If, as in certain cases of chronic ulceration, 
e. g., in phthisis, amyloidosis is also a factor, the failure of absorp- 
tion may be due not to the ulcers alone. 

The most characteristic symptom of intestinal ulcers is the find- 
ing of blood, pus, certain forms of mucus and particles of tissue in 
the feces. Blood may occur in various ways. If there is a profuse 
hemorrhage, it is, of course, immediately and easilv recognizable, 
even if the hemorrhage has occurred as high up as the duodenum. 
On the other hand, there may be only minute hemorrhages, from 
capillary erosions, and the blood may be so intimately mingled 
with the fecal matter as to escape detection by macroscopic exam- 
ination. The higher the seat of the ulcer, the more is the blood 
altered in its passage, and the more intimately does it become 
mingled with the fecal masses. In these cases, it is only a micro- 
scopical examination or a chemical examination which serves to 
reveal the blood. Microscopically, one may find either blood cor- 
puscles, more or less altered, or crystals of hematin. The former 
are more apt to occur in case of colon ulcerations, the latter with 
disease of the upper bowel. It is very remarkable that the various 
kinds of ulcers behave very differently with respect to their ten- 
dency to bleed. Typhoid and dysenteric ulcers are far more apt 
to produce hemorrhage than are tuberculous or catarrhal ulcers. 
Indeed, the latter may run their entire course without any trace 
of hemorrhage. The significance of blood in the stools is thus 
formulated by Xothnagel : If blood occurs in the stools under cir- 
cumstances which permit of the possibility of ulcers, the diagnosis 
of the latter condition becomes extremely probable. The absence 



318 EXAMINATION OF THE FECES. 

of blood is no argument against the existence of ulcers. It is 
important to remember that blood in the stools may occur in case 
of epistaxis, pharyngeal hemorrhage, and anemias — causes which 
must be excluded before entertaining the diagnosis of intestinal 
ulceration. 

Pus is even more characteristic than blood in the feces of ulcera- 
tive enteritis. Exudation of leucocytes is practically absent in 
cases of simple catarrh of the intestine, and may be considered 
pathognomonic of ulceration, whether this be simple or neoplastic. 
Pus occurs in the feces in certain other rare conditions, e. g. 3 the 
perforation of extra-intestinal abscesses. The amount of pus 
varies very greatly. At times, large amounts of almost pure pus 
are voided. This occurs especially with the perforation of 
abscesses, with ulcerated carcinomata, and with extensive dysen- 
teric processes. In the majority of cases of simple ulceration, only 
small amounts of pus pass out in the stool, and very careful search 
may be necessary to demonstrate them. Characteristic are the 
minute, yellowish-white clumps, which microscopical examination 
reveals as conglomerates of pus cells. In many cases, however, 
the leucocytes are digested and altered beyond recognition in their 
passage, and this is the more apt to occur, the higher up the seat of 
the ulceration. Moreover, certain types of ulcer, e. g«, the duodenal 
ulcer, tend not to produce pus. Its absence, therefore, cannot be 
held to exclude the diagnosis of ulcer. Pure pus is found practi- 
cally in only two conditions — perforation of extra-intestinal 
abscesses and diphtheritic enteritis. In dysentery, and in ulcer- 
ated carcinomata located in the lower colon and rectum, there is 
pus mixed in almost equal proportions with blood and mucus. 

Shreds of tissue, if of recognizable origin, are direct evidence of 
ulceration. It is essential to distinguish them from food rem- 
nants, a task not always easy. They occur with especial frequency 
in dysentery, and often in neoplastic ulcerations, while they may be 
entirely lacking in typhoidal and other ulcerations of the gut. The 
search for bacteria is often of importance in intestinal ulceration. 
If a Gram stain is made of the fecal matter, or of a particle of 
isolated pus, it will generally be found that the stain contains far 
more Gram positive organisms than is normal, which reveal them- 
selves, on closer examination, as cocci. Not every case of strepto- 
coccus enteritis is of necessity ulcerative, but this change in the type 
of intestinal flora must always be regarded with a Hgh degree of 
suspicion. The examination for specific organisms is far more 
difficult, and liable to much error. Tubercle bacilli are a frequent 



CHARACTERISTIC PICTURES IN DISEASE. 319 

object of search. Unfortunately, it is practically impossible, by 
ordinary clinical methods, to differentiate positively between the 
tubercle bacillus and the hay bacillus, which is often found in 
normal stools. For this purpose it becomes necessary either to 
isolate the questionable acid-fast organism by the ordinary method 
of plate cultures, often a very laborious procedure, and then to test 
its biological characters, or to determine its pathogenicity by injec- 
tions into guinea-pigs. But even the presence of demonstrated 
genuine tubercle bacilli does not prove the existence of an ulcera- 
tive tuberculosis of the intestine, inasmuch as the bacilli of the 
sputum are frequently swallowed in large numbers, and pass out 
in the feces unaltered. It is only in combination with other posi- 
tive evidences of ulceration that the presence of tubercle bacilli in 
the feces should be taken to indicate a specific ulcerative process 
of the intestine. The finding of dysentery and typhoid bacilli will 
be treated of more especially in a subsequent subdivision, as will 
also the presence of amoebae. 

Typhoid. — It was at one time customary to speak of "typhoid 
stools" as characteristic to a great degree of the disease. They 
are described as diarrheal, watery, of "pea-soup" like consistency. 
On standing, they separate into a whitish-yellow, crumbly sedi- 
ment, and a turbid supernatant fluid. In color they are light yel- 
low ; in odor, disagreeable ; in reaction, markedly alkaline. It is 
now well known that this "typical" stool occurs by no means in all 
cases, and in some epidemics is present in only a small proportion 
of the cases. Indeed, there may be no diarrhea, and the stools may 
be normal in form and consistency throughout. The causes under- 
lying the differences are not at all understood. The stools often 
present slight traces of hemorrhage, which may be evident as red 
streaks along the exterior of the fecal column, or intimately 
mingled with it. or may first reveal themselves to microscopic ex- 
amination. It is believed by Xothnagel that these slight hemor- 
rhages are to be regarded very frequently as the precursors of more 
profuse losses. Pus cells are present, as is mucus, in small 
amounts in many cases of typhoid. The examination of the stools 
for typhoid bacilli has been described in the section on bacteriolog- 
ical technique. The whole matter of typhoid and paratyphoid 
diagnosis from the stools is constantly becoming more complicated 
and confused, so that it is difficult at the present moment to decide 
as to its clinical value. When the Koch school accepted the pro- 
cedure known as that of Drigalski-Conradi, and previously 
described, it became customarv to identifv the doubtful colonies 



320 EXAMINATION OF TEE FECES. 

by means of their agglutinability by high-titer serum of rabbits. 
In this manner, typhoid bacilli were isolated from the stools in a 
large proportion of the cases in certain typhoid epidemics, and the 
paratyphoid form in the same manner in a certain specific epidemic 
caused by it in the military garrison of Saarbriicken (Conradi). 
Furthermore, it was not unusual to discover the specific bacilli in 
the stools of many individuals presenting very slight symptoms, 
or even none at all, during the time of such epidemics, and these 
cases were identified by Koch as typhus levissima, or as "im- 
munes," in the same manner as such cases are to be found in every 
cholera epidemic. Recently it has been found, however, that 
many true typhoid bacilli do not agglutinate well. Indeed, this 
fact has been the basis of a subdivision by Sacquepee of the typhoid 
group into "Eberths," which agglutinate, and "Eberthiformes," 
which agglutinate poorly. On the other hand, non-typhoid bacilli 
often agglutinate extremely well with typhoid serum, owing prob- 
ably to the existence of amboceptors which have more or less affin- 
ity for the entire group of related organisms. As a result of these 
conditions, it might have been expected that very serious confusion 
would result, as has indeed occurred. Conradi has described cases 
of paratyphus bacilli in the stools of typhoid patients, Altschiiler 
has found typhoid organisms in the blood of patients whose serum 
agglutinated paratyphoid in the highest dilution, and Jurgens 
has obtained such irreconcilable results that he advocates complete 
disregard of the newer subdivisions, and a return to the old clinical 
entity of typhoid fever, regardless of cultural determinations. It 
is, therefore, safe to say that for the present bacteriological exami- 
nation of the stools should be left to acknowledged experts, and 
even their, results accepted with caution. 

Asiatic Cholera and Cholera Nostras. — The stools in Asiatic chol- 
era occasionally resemble those of simple diarrhea, but in 
the majority of cases they are very characteristic of the con- 
dition. In cases of any degree of severity, they no longer resem- 
ble feces, but consist of a very thin, fluid material, of a gray or 
whitish color, in which are suspended minute floecules or granules. 
These are the characteristic rice-water stools, and they are voided 
with great frequency, so that during the course of* twenty-four 
hours liters may be lost. The odor of the stools is no longer fecal, 
but rather albuminous, like spermatic fluid. The reaction is alka- 
line or neutral. Occasionally the fluid, instead of being colorless, 
is tinged with red by blood, and then resembles a beef-broth. 
Chemical examination shows that the fluid contains only 2 per 



CHARACTERISTIC PICTURES IN DISEASE. 321 

cent, of solid constituents, of which sodium chloride composes a 
great part. Of albumin there is little. The rinding of cholera 
bacilli has been already described, and offers an easy method for 
the identification of the disease. 

Dysentery. — The stools in dysentery are characteristically com- 
posed of mucus, pus, and blood, mixed in varying proportions 
in a fluid or semi-solid stool. The stools are not large, but are very 
frequently voided. Germans distinguish popularly between cases 
of "white" dysentery, in which the amount of blood lost is small, 
and "red" dysentery, in which large enough amounts to color the 
fecal fluid are lost. Peculiarly firm masses of mucus, often par- 
tially blood-stained ( "caruncuke" of the older authors) are also 
found. Necrotic masses of mucus membrane are also not rare. 
The stools may have no odor, or a gangrenous odor. The bacilli 
are easily found in the mucus. 

Amoebic dysentery. — The stools are, as a rule, fluid and frequent. 
They have a fecal color, and a peculiar, slightly mucilaginous odor. 
They contain, as a rule, large amounts of mucus, and very often 
distinct traces of blood. The reaction is invariably alkaline. The 
microscopic examination of the fresh mucus discloses epithelia, 
red blood cells, and most characteristic organisms. These having 
already been described in detail, nothing further need be said of 
their appearance. 

Carcinoma. — The stools of carcinoma of the intestine are char- 
acteristic only in case the new growth is situated in the large intes- 
tine. Carcinoma of the small gut cannot be diagnosticated from 
the character of the stools. Several factors, which generally occur 
in conjunction in cases of new growth of the colon or rectum which 
have attained any considerable size, combine to alter the character 
of the stool. These are, the stenosis which it occasions, its ulcera- 
tion, and the associated catarrh of the bowel. The stenosis occa- 
sions a constipation which may persist obstinately for days. In 
some cases, ulceration of the growth provides a freer passage again, 
a fact which is generally documented by the initial passage of 
blood, pus, or fragments of tissue. 

Certain cases, on the other hand, present periods of severe diar- 
rhea, due to the catarrh which so frequently accompanies carci- 
noma. It is very unusual, however, that the diarrheas should per- 
sist throughout the course of the disease, As a rule, they are inter- 
rupted, or terminated, by a period of constipation due to the 
obstruction occasioned by the growth. Thus the character of the 
stools is very variable. At times they are quite normal. Again, 
21 



322 EXAMINATION OF THE FECES. 

they may show all the earmarks of stenosis ; of small caliber, flat- 
tened, lead-pencil like, or similar to the stools of goats, Mucus 
may be present in large amounts, or may be absent, depending on 
the degree of coincident catarrh. Blood appears in the feces with 
a considerable degree of frequency, although by no means in all 
cases. It is most apt to occur in ulcerated new growths, in which 
case it may appear with regularity in every stool, in larger or 
smaller amounts, but it is occasionally found in connection with 
cancers which at autopsy present a perfectly intact surface. In 
the latter case, it must be supposed that minute hemorrhages are 
occasioned by the passage of scybalous masses through the nar- 
rowed portion of intestine. Pus is found only in case of ulcera- 
tion, and is generally present in amounts directly commensurate 
with the loss of surface. In the deeply exulcerated new growths of 
the colon, pus may be fairly profuse. The presence of any two 
of these symptoms in the stool, stenotic stools, pus, or blood, points 
with great probability to the diagnosis of cancer of the colon. 
Indeed, a mixture of blood and muco-purulent masses, such as is 
found in many of these cases, occurs in only one other condition, 
namely, dysenteric ulceration of the intestine, which is, as a rule, 
easily differentiated by other symptoms. The diagnosis is, of 
course, definitely determined if one is fortunate enough to discover 
particles of the new growth itself in the feces, a fairly rare occur- 
rence. 

In carcinoma of the rectum, all of the above-mentioned symp- 
toms occur with increased intensity. There is apt to be much 
blood and pus, and the odor of the stools is often gangrenous. 

Amyloidosis. — The diagnosis of intestinal amyloidosis can never 
be made from the examination of the stools alone, although 
they afford an essential factor in its recognition. The stools are 
watery, and contain fecal matter which is generally insufficiently 
digested. Blood and pus are absent in uncomplicated cases. These 
characteristics are due to failure of the digestive and of the absorp- 
tive faculties of the intestine. 

Icterus. — The stools are typically white, alcoholic, and rich in 
fats. They may be firm, or there may be a diarrhea, set up by the 
fermentation of the intestinal contents. The fat is usually present 
as the lime and magnesium salts of the fatty acids, which appear as 
tufts or sheaves of needle-like crystals. These crystals resist the 
action of the mineral acids. 

Pancreatic Disease. — The essential character of the stools of 
pancreatic disease depends upon the fact that with it the 



CHARACTERISTIC PICTURES IN DISEASE. 323 

intestine is robbed of its digestive ferments. As is well known, 
all three of the chief constituents of the diet — starches, proteids 
and fats — depend at once on the pancreatic juice for their com- 
plete alteration, and in its absence the process of digestion is almost 
completely inhibited. To a certain extent, the starches and fats, 
altered and split up by the gastric juice and by the bacteria, are 
still capable of absorption, but in most cases a great portion of 
them passes out in the feces partially undigested. The proteid 
constituents, muscle fibers, etc., are most apt to be found in the 
stools, characteristically in fairly large masses. Fats are found 
typically as globules of neutral fat, but may be entirely absent from 
the stool. Starches are an evidence of the most severe disturb- 
ances. They occur in pancreatic disease, as a rule, only when con- 
joined with a very active peristalsis which hurries the food with 
more than normal rapidity through the gut. Otherwise there are 
no characteristic alterations of the 'stool in pancreatic disease. 



INDEX 



Acetone in urine. 47 
tests for, 99 

Denniges-Oppenheimer, 100 
Reynolds, 99 
Stock-Frohner, 100 
Acid, /3-oxv butyric, in urine, tests for, 
101 
chrvsophanic. in urine, tests for, 

108 
diacetic. in urine, tests for. 100 
Arnold's. 101 
Gerhard's. 100 
hippuric. in urine. 39 

tests for. 64 
homogentisinic. in urine, 50 
lactic, in urine. 51 

tests for. 106 
oxalic, iir urine, 40 

tests for, 65 
oxaluric, in urine. 40 
producing bacilli, 208, 210 
salicylic, in urine, tests for. 108 
tannic, in urine, tests for, 109 
taurocarbaminic, in urine, 41 
uric, form of crystals, 114 
qualitative test for. 59 
quantitative test for. 39 
in urine, 38 
uroleucinic. in urine, 50 
Acids, fatty, action of colon bacilli on. 
184 
crystals of, 183 
volatile, fatty, in urine, tests for, 
107 
in urine. 51 
Actinomyces in urine. 141 
Albumin in urine, 43 

delicacy of. tests for, 77 
differential densitv. method for, 

79 
estimation of. by boiling, 79 
Brandenburg's. 78 
Ensbach's, 77 
Wassilieros. 78 
tests lor. alcohol. 76 

beta-naphtholsulphonie acid, 76 
boiling. 73 
ferrocyanide. 74 
Heller's ring test. 72 
Jolle's, 75 
metaphosphoric, 76 



Albumin in urine, tests for, picric acid 
76 
qualitative, 72 
quantitative, 77 
resorcine, 76 
Roberts' 75 
Spiegler's. 75 
sulphosalicylic acid. 74 
trichloracetic acid, 75 
Albuminuria, accidental, 44 

renal. 44 

orthostatic. 44 
Albumose in urine. 43 

te^ts for. 79 
Aleurone grains, 201 
Alkali-producing bacilli, 206. 209 
Alkaline-producing bacteria, 206 
Alkapton in urine. 50 

tests for. 105 
Alkaptonuria, 50 
Alloxur bases in urine, tests for, 63 

bodies in urine, 39 
Amebae in urine, 133 
Amido-acids in urine, tests for, 64 
Ammonia in urine, 42 

tests for, 70 
Ammonium urate, form of crystals, 

120 
Amoeba. 264 

coli. 267 

mitis, 267 

intestini vulgaris, 267 
Amyloidosis, stools of. 322 
Anchylostomum duodenale, 275 
Animal parasites, 264 
Anuria, 2\) 

reflex. 29 
Antipyrine in urine, tests for, 109 
Arnold's test for diacetic acid, 101 
Arnstein's method for purin bases. 63 
Arsenic in urine, tests for. 108 
Ascaridse, 270 
Ascaris lumbricoides. 271 



B 

Bacilli, acid-producing. 208. 
alkali-producing. 206, 209 
Bienstock's group of. 208 
Booker's group of. 207 
cloaca^, group of. 208 
dubius, group of, 211 
dysenteric, group of, 207 



10 



(325) 



326 



INDEX. 



Bacilli, Eisenberg, group of, 210, 240 

enteric, group of, 207 

hog-cholera, group of, 207 

Kruse, group of, 211 

liquefaciens, group of, 210, 240 
Bacillus acidophilus, 216 

alcalescens, 217 

alcaligenes, 212 

aquatilis sulcatus, 260 

arachnoideus, 260 

Booker's, 226 

Breslaviensis, 262 

brevis, 258 

caeci, 225 

cereus, 253 

chylogenes, 243 

cloacae, 241 

coli, 231 

coli immobilis, 261 

communior, 234 

coprogenes parvus, 261 

dubius, 245 

Dunham's, 234 

dysenteric, 213 

Eberth's, 215 

entericus, 220 

enteritidis, 218 

foetidus, 261 

.Cartner's, 218 

gastricus, 239 

Hauser's, 222 

iliacus, 242 

infrequens, 222 

jejunalis, 246 

Jordan's, 241 

leporis, 244 

Migula's, 212 

Moro's, 216 

Miiller's, ^i3 

mycoides, 254 

cedematis serobius, 261 

oxyphilus, 228 

phlei, 261 

plebeius, 221 

pseudo dysentericus, 213 

putrificus, 261 

pylori, 224 

pyocyaneus, 226 

and green stools, 165 

Ravenal's, 249 

recti, 223 

Shiga, 213 

subalcalescens, 218 

subcloacre, 242 

subentericus, 221 

subgastricus, 239 

subtilis, 259 

tuberculosis, 261 

typhi, 215 

vulgaris, 222 

vulgatus, 257 

Weil's, 226 
Bacteria, alkaline-producing, 206 



Bacterial system, 206 
Bacteriology of feces, 204 

of urine, 135 
Bacterium acidoformans, 229 

serogenes, 236 

anthracoides, 252 

Bienstockii, 227 

chymogenes, 244 

duodenale, 238 

galactophilum, 219 

Havaniense, 250 

implectans, 253 

lacticola, 255 

liquefaciens, 240 

lutescens, 251 

minutissimum, 230 

oxygenes, 227 

subliquefaciens, 240 

vermiculare, 256 
Balance, Mohr-Westphal, 32 
Balantidium coli, 268 
Beck's estimation of sugar in urine, 94 
Bence-Jones bodies in urine, 45 

tests for, 81 
j3-oxybutyric acid in urine, 48 
Bial's test for pentose in urine, 98 
Bienstock's group of bacilli, 208 
Bile-acids in urine, 48 

pigments in urine, 48 
tests for, 102 
Huppert's, 103 
Jolle's, 103 
Rosenbach's, 103 
Smith's, 102 
Bilharzia hematobia in urine, 132 
Bilirubin, 164 

form of crystals, 119 
Biliverdin, 171 
Bismuth in stools, 168 
Blood, chemical examination for, 307 

in feces, origin of, 190 

in stools, 167 
Bone tumors, urine in, 153 
Booker's bacillus, 226 

group of bacilli, 207 
Bothriocephalidse, 283 
Bothriocephalus cordatus, 292 

latus, 290 
Brandenburg's estimation of albumin, 

78 
Bromides in urine, tests for, 108 
Briicke's test for sugar in urine, 84 



Calcium, form of crystals, carbonate, 
119 
oxalate, 115 
phosphate, primary, 115 

secondary, 116 
sulphate, 117 
oxalate crystals in feces, 186 
Calomel in stools, 168 
Carbohydrates, 304 



INDEX. 



327 



Carbonates in mine. 42 
Carcinoma, stools of, 321 
Casein in feces, 179 
Casts, hyaline, 129 

testicular, 132 

in urine, 127 

waxy, 130 
Cells, epithelial caudate, 125 
flat, 125 
round, 124 

in urine, epithelial, 121 
red, 126 
Cellulose, digestion of, 193 

in feces, 192 
Cestode worms, 282 
Charcot-Leyden crystals, 185 
Chemical examination of feces, 295 

methods of. 295 
Chlorides in urine, 41 

test for; qualitative, 69 
quantitative, 68 
Chloroform in urine, tests for, 109 
Chlorophyll, 194 
Cholera, stools of, 320 
Cholesterin, 185 

form of crystals, 121 

in urine, 50 
Chromogens in urine, 40 
Chyluria. 132 
Citron's estimation of sugar in urine. 

94 
Clay-colored feces and jaundice, 169 
Cloacae group of bacilli, 208 
Colitis, muco-membranous, 315 
Colon bacilli, action of, on fatty acids, 

184 
Conjugate sulphates in urine, 42 
Copaiba in urine, tests for, 109 
Cotton tibre in urine, 134 
Cryoscope, 35 
Cryoscopy, 22. 34. 149 
Crystalline salts, 185 
Crystals of fatty acids, 183 
Cultures from feces. 205 
Cylindroids in urine. 131 
Cystin. form of crystals, 121 

in urine. 50 
tests for, 105 
Cystitis, urine in, 153 

D 

Defecattox, duration of, 158 
frequency of, 157 

Denniges-Oppenheimer test for ace- 
tone in urine. 150 

Diabetes insipidus, urine in, 153 
mellitus. urine in, 153 

Diacetic acid in urine, 47 

Diarrheas, fat. of infants, 182 

Dipylidium caninum, 292 

Dochimus duodenalis, 275 

Donogany's test for hemoglobin, 102 



Doremus' apparatus for urea, 56 
Drugs in urine, 52 

tests for. 107 
Dubius group of bacilli, 211 
Dunham's bacillus, 234 
Dysenteric group of bacilli, 207 
Dysentery, amebic, 265 
Stools of. 321 



Eberth's bacillus, 215 
Eehinococcus in urine, 133 
Eisenberg group of bacilli, 210, 240 
Ensbach's estimation of albumin, 77 
Enteric group of bacilli, 207 
Enteritis, acute, fecal characteristics 
of, 313 
chronic, fecal characteristics of, 314 
diphtheritic, fecal characteristics 
of, 315 
Eosinophiles in feces. 189 
Epithelium in feces, 187 
Erythrocytes in feces, 190 
Ethereal sulphates in urine, 42 
Eustrongylus gigas in urine, 133 
Examination, bacterial, of feces, meth- 
ods of, 204 



Fat. chemical examination for, 306 
in urine. 49. 132 

tests for. 104 
Fecal matter, amount of in twenty- 
four hours. 160 
Feces, animal food in, 180 

bacterial examination of, methods 

of. 204 
bacteriology of, 204 
biliary concretions in. 175 
blood in, origin of, 190 
calcium oxalate crystals in, 186 
casein in.- 179 
cellulose in, 192 
chemical examination of, 295 

methods of. 295 
clay-colored, and jaundice, 169 
consistence of, 162 
connective tissue in, 179 
cultures from, 205 
elastic ussue in, 179 
eosinophiles in, 189 
epithelium in, 187 
erythrocytes in, 190 
fat in. 170. 181 
foreign bodies in, 176 
form of. 162 
from infants, method of obtaining, 

204 
hemin crystals in. 185 
influence of age upon amount of, 
161 

of digestion upon amount of, 162 



328 



INDEX. 



Feces, influenced by food, 160 
leucocytes in, 189 
v macroscopic elements of, 172 
meat residue in, 177 
medico-legal interest in, 201 
microscopical examination of, re- 
agents for, 177 

stains used in, 177 
mucus in, 166, 173 
muscle fibres in, 178 
odor of, 171 

oxalate of lime crystals in, 186 
pus in, 174, 189 
reaction of, 296 
seeds m, 199 
soaps in, 183 
starcn in, 194 
causes of, 195 

Schmidt's sublimate test for, 305 
.Fleischer's test for, 305 
sterile, 205 
sugar in, 304 
tumors in, 190 
undigested food in, 172 
vegetable detritus in, 191 
vegetable proteids in, 181 
Fehling's estimation of sugar in urine, 
93 
test for sugar in urine, 85 
Ferments in urine, 40 

tests for, 66 
Fevers, urine in, 152 
Fibrin in urine, 45 

tests for, 82 
Filaria in urine, 133 
Fleischer's test for starch in feces, 305 
Folin's method for ammonia in urine, 
70 
for urea, 58 
for uric acid, 60 
Food residue, 166 

undigested, in feces, 172 



Gall-stones, 175 

Gartner's bacillus, 218 

Gases in urine, tests for, 107 

Gerhardt's test for diacetic acid, 100 

Glucose in urine, 46 

Glycosuria, 46 

Glvcuronic acid in urine, 41, 47 

tests for, 98 
Gmelin's reaction, 306 
Gonococci, staining of. 137 

in urine, 137 
Gout, urine in, 153 
Gram's stain, 205 
Gunning's mixture, 54, 155 



H 



Hauser's bacillus, 222 

Havcraft's method for uric acid, 60 



Heller's test for albumin, 72 

hemoglobin, 102 
Hem in crystals in feces, 185 
Hemoglobin in urine, 48 
tests for, 101 
aloin, 102 
Donogany's, 102 
guaiacum, 102 
Heller's, 102 
Hemato-porphyrine, 52 
Hematoidin form of crystals, 119 
Hemophilia, renal, 127 
Hemorrhagic stools, 175 
Histon in urine, 45 

tests for,. 82 
Hog-cholera group of bacilli, 207 
Homogentisinic acid in urine, 50 
Hopkins' method for uric acid, 59 
Hoppe-Seyler's test for sugar in urine. 

89 
Horsley-Pratesi's test for sugar in 

urine, 89 
Huppert's test for bile pigments, 103 
Hydrobilirubin, 305 
Hydrometer, Jolle's, 3z 
Hymenolepsis diminuta, 289 
nana,, 286 

I 

Indican in urine, 40 

test for qualitative, 66 
quantitative, 66 

Indigo, form of crystals, 121 

Infants, bottle-fed, 'fecal, bacilli of, 206 
breast-fed, fecal bacilli of, 205 
method of obtaining feces from, 204 

Inosite in urine, 47 

Intestinal disease, urine in, 152 

Intestine, ulcers of, 316 

Iodides in urine, tests for, 108 

Iron salts in urine, 42 
in stools, 168 



Jaundice, clay-colored feces of, 169 
Jolle's test for albumin, 75 

for bile pigments, 103 
Jordan's bacillus, 241 

K 

Kidney, anatomy of, 17 

effects of nephrectomy on remain- 
ing, 26 

pathology of, 23 

physiology of, 17 

vascular changes in, 24 
Kino in stools, 168 
Kjehldahl's test for nitrogen, 53 
Knapp's estimation of sugar in urine, 

95 
Kreatinin in urine, 38 

tests for, 64 
Kruse group of bacilli, 211 



INDEX. 



329 



L, 

Lactic acid in urine, 51 
Lactose in urine, 46 
tests for, 97 
Rubner's, 97 
"Lead-pencil" stools,' 163 
Lead in urine, tests for, 107 
Lea's sugar in urine, 47 

tests for, 98 
Leuein form of crystals, 118 
in urine, 50 
tests for, 104 
Leucocytes in feces, 189 
in urine, 126 

counting of, 126 
Leukemia, urine in, 153 
Levulose in urine, 46 

reaction for, Seliwanoffs, 98 
tests for, 98 
Levulosuria, in hepatic disease, 46 
Lining, epithelial, of genito-urinary 

tract, 121 
Lipuria, 49 

Liquefaciens group of bacilli, 210, 240 
Liver disease, urine in, 153 
Lycopodium in urine, 134 

M 

Maltose in urine, 47 

tests for, 98 
Maschke's test for sugar in urine, 85 
Meconium, 191 

Medico-legal interest in feces, 201 
Melanin in urine, 102 

tests for, 102 
Mercury in urine, tests for, 107 
Micrococcus urege in urine, 141 
Miquel's method for urea, 58 
Migula's bacillus, 212 
Mineral sulphates in urine, 41 
Moeller's reaction, 194 
Mohr- Westphal balance, 32 
Molecular concentration of urine, 34 
Moore's test for sugar in urine, 87 
Morner and Sjoquist's method for 

urea, 59 
Moro's bacillus, 216 
Morphine in urine, tests for, 109 
Mucin, chemical examination for, 304 

in urine, 45 
Mucus in feces, 166, 173 

origin of, 187 
Muller's bacillus, 213 

N 

Naphthaline in urine, tests for, 109 

Nematodes, 271 

Nephrectomy, effects of on remaining 

kidney, 26 
Neubauer and Salkowski's method for 

chlorides in urine, 69 
Nitrates in urine, 42 



Nitrogen content, 299 

in urine, distribution of, 55 
tests for, 53 
Nothnagel's bodies, 190 
Xubecula in urine, 30 
Xucleo-albumin in urine, 45 
tests for, 81 
histon in urine, 45 
Xvlander's test for sugar in urine, 83 



Obermayee's reagent, 66, 155 
Oliguria, 29 

Orthoform in urine, tests for, 109 
Osmotic pressure of urine, 34 
Oxalate of lime crystals in feces, 186 
Oxalic acid in urine, 40 
Oxaluric acid in urine, 40 
Oxyuris, 269 

vermicularis, 272 



Pancreatic disease, 178 

and fat absorption, 184 
Pappenheim's method for staining 

tubercle bacilli, 137 
Parasites, animal, 264 

in urine, 132 
Pentoses in urine, 47 
tests for, 98 
Bial's, 98 
Penzoldt s test for sugar in urine, 89 
Peptone in urine, 45 

tests for, 80 
Phenol in urine, 41 

tests for, 106 
Phenacetine, in urine, tests for, 109 
Phloridzine. 148 
Phosphate, triple, 116 
Phosphates in urine, 42 

test for, qualitative, 70 
quantitative, 70 
Pigments in urine, 40 

tests for, 66 
Pneumaturia, 52 
Polyuria. 29 
Potassium chlorate in urine, tests for, 

108 
Pre-formed sulphates in urine, 41 
Preservation of urinary sediment, 142 

of urine, 113, 142 
Protozoa, 264 
Pseudomonas aeruginosa, 247 

ovalis, 249 
Ptomains in urine, tests for, 107 
Purin bases in urine, tests for, 63 

bodies in urine, 39 
Purinometer, 63 
Pus in feces, 174, 189 
Pyelitis, urine in, 153 
Pyknometer, 32 
Pvramidon in urine, tests for, 109 



330 



INDEX. 



R 

Ravenal's bacillus, 249 
Reaction, diazo, 50, 105 

dimethylamidobenzaldehyde, 51, 106 

of feces, 296 

pancreatic, 51 

Rosenbach's, 106 

of urine, 33 

methods of determining, 33 
Reagents for urinalysis, 154 
Refractometer, 142 
Renal disease, urine in, 152 
Residue, 297 

Resorcine in urine, tests for, 110 
Retention of urine, 29 
Reynolds' test for acetone in urine, 99 
Rhubarb crystals, 201 

in stools, 168 
Roberts' test for albumin, 75 
Rosenbach's reaction, 106 

test for bile-pigments, 103 
Rubner's test for lactose, 97 

sugar in urine, 87 
Rudish's method for uric acid, 61 



Sacchakometer, Einhorn's, 90 

Lohnstein's, 97 
Sahli's capsules, 178 
Salkowski's method for purin bases, 
63 
Volhard's method for chlorides in 
urine, 68 
Santonin in stools, 168 

in urine, tests for, 108 
Schlosing's method for ammonia in 

urine, 71 
Schmidt's sublimate test, for starch in 

feces, 305 
Scybalee, 163 
Secretion of urine, 17 
Seeds in feces, 199 
Seliwanoff's test for levulose, 98 
Senna in stools, 168 
Sepsis, urine in, 138 
Serum albumin, properties of, 43 
in urine, 43 
globulin, properties of, 44 
tests for qualitative, 79 

quantitative, 82 
in urine, 44 
in stools, 167 
"Sheep stools," 163 
Shiga bacillus, 213 
Simon's apparatus for urea, 57 
Skatol in urine, 40 
Skatoxyl in urine, tests for, 106 
Smegma bacilli in urine, 136 
Smith's test for bile-pigments, 102 
Soaps, form of crystals, 119 
Specific gravity of urine, 31 

methods of determining, 32 



Spermatazoa in urine, 131 
Spiegler's test for albumin, 75 
Spirillum choleree Asiatic®, „263 
Gottschlick, 263 
helcogenes, 263 
Lisbon, 263 
Massanah, 263 
proteus, 263 
Squibb's apparatus for urea, 58 
Staphylococcus albus, 263 
aureus, 263 
citreus, 263 
Starch in feces, 194, 304 
causes of, 195 
tests for, 195 
in urine, 134 
varieties of, 197, 199 
Stock-Frohner's test for acetone in 

urine, 100 
Stomach disease, urine in, 152 
Stones, chemical examination of, 111 
general properties of, 111 
renal and bladder, 111 
Stools, amount of, 158 
of amyloidosis, 322 
blood in, 167 
of carcinoma, 321 
of cholera, 320 
color of, 163 

colorless, without jaundice, 170 
drugs in, 168 
of dysentery, 321 
green, 171 

green, and bacteria, 169 
hemorrhagic, 175 
intervals between, 157 
serum in, i67 
typhoid, 319 
Streptococcus coli brevis, 262 
gracilis, 262 
pyogenes, 262 
Strongyloides intestinalis, 279 
Strongylus duodenalis, 275 
Sugar in feces, 304 
in urine, 45 

delicacy of, tests for, 93 
differential density of, method of 

determining, 96 
estimation of, Beck's, 94 
Citron's, 94 
Fehling's, 93 
Knapp's, 95 
separation of, from urine, 93 
tests for, Brucke's, 84 
Fehling's, 85 
fermentation, 90, 97 
furfurol, 89 
heating, 88 
Hoppe-Seyler's, 89 
Horsley-Pratesi's, 89 
Maschke's, 85 
methylene blue test, 88 
Moore's, 87 



INDEX. 



331 



Sugar in urine, tests for, Nylander's, 83 
Penzoldt's, 89 
phenylhydrazine, 92 
picric acid, 88 
polariscope, 91, 97 
qualitative, 83 
quantitative. 93 
Ribner's, 87 

sodium sulpho-indigotate, 88 
Trcmmer's, 86 
Sulphates in urine, 41 
conjugate, 42 
ethereal, 42 
mineral, 41 
pre-formed. 41 

test for. qualitative, 69 
quantitative, 69 
Sulphocyanides, in urine, 41 
Sulphonal in urine, tests for, 109 
Sulphur, neutral, in urine, 41 

tests for, 68 
Suppression of urine, 29 
Suppurations, urine in, 153 
Suppurative nephritis urine in, 153 



Taenia, 269 

Africana. 289 

cucumerina, 286 

nana, 286 

saginata, 285 

solium, 283 
Taurocarbaminic acid in urine, 41 
Thompson's two-glass test, 126 
Threads, gonorrheal, 137 
Trematode worms,, 292 
Trichina spiralis, 282 
Trichocephalus dispar, 280 
Trichomonas vaginalis in urine, 132 
Trional in urine, tests for, 109 
Trommer's test for sugar in urine, 86 
Tubercle bacilli, staining of. 136 
Pappenheim's method, 137 
Tiehborne's method for uric acid, 59 
Tumor particles in urine, 132 
Tumors in feces, 190 

urine in, 152 
Turpentine in urine, tests for 109 
Typhoid bacilli, identification of, 139 
'stools, 319 

urine in, 139 
Tyrosin, form of crystals, 118 

in urine. 50 
tests for, 104 



UJ 

Ulcers of the intestine, 316 
Uncinaria, 275 

Americana, 278 
Urates, form of crvstals, 115 



Urea, method for estimating, Dore- 
mus, 56 
Folin's, 58 
Miguel's, 58 

Morner and Sjoquist's, 59 
Simon's, 57 
Squibb's, 58 
nitrate, 56 

qualitative, test for, 55 
urine, 37 
Uric acid, method for, Folin's, 60 
Haycroft's, 60 
Hopkins', 59 
Rudish's, 6L 
Tiehborne's, 59 
test for, qualitative, 59 

quantitative, 59 
in urine, 38 
Uricometer, 60 

Urine, abnormal constituents of, 43 
acetone in, 47 
tests for, 99 

Denniges-Oppenheimer, 100 
Reynolds', 99 
Stock-Frohner, 100 
acid in, hippuric, tests for, 64 

oxalic, tests for, 65 
actinomyces in, 141 
action on polarized light, 41 
albumin in, 43 

delicacy of, tests for, 77 
differential density, method for, 

79 
estimation of, by boiling, 79 
Bradenburg's, 78 
Ensbach's, 77 
Wassiliero's, 78 
serum, 43 
tests for alcohol, 76 

beta-naphtholsulphonic acid, 76 
boiling, 73 
ferrocyanide, 74 
Heller's ring test, 72 
Jolle's, 75 
metaphosphoric, 76 
picric acid, 76 
qualitative, 72 
quantitative, 77 
resorcine, 76 
Roberts', 75 
Spiegler's, 75 
sulphosalicylic acid, 74 
trichloracetic acid, 75 
albumoses in, 44 

tests for, 79 
alkapton in, 50 
tests for, 105 
alloxur bases in, tests for, 63 

bodies in, 39 
amebse in, 133 
amido-acids in, tests for, 64 
ammonia in, 42 

Folin's method for, 70 



332 



INDEX. 



Urine, ammonia in, Schlosing's method 
for, 71 

tests for, 70 
amount excreted, 29 
amorphorous deposits in, 114 
antipyrene in, tests for, 109 
appearance of, 30 
arsenic in, tests for, 108 
bacilli in, colon, 139 
smegma, 136 
tubercle, 136 
typhoid, 139 
bacteriology of, 135 
behavior towards reagents, 36 
Bence-Jones bodies in, 45 

tests for, 81 
/?- oxybutyric acid in, 48 

tests for, 101 
bile acids in, 48 
pigments in, 48 
tests for, 102 
Huppert's, 103 
Jolle's, 103 
Bosenbach's, 103 
Smith's, 102 
bilharzia hematobia in, 132 
bone-tumors in, 153 
bromides in, tests for, 108 
carbonates in, 42 
casts in, 127 
cells in epithelial, 121 

red, 126 
centrifuging of, 113 
changes of, in bladder, 28 
chemistry of, 36 
chlorides in, 41 

Neubauer andSalkowski's method 

for, 69 
Salkowski-Volhard's method for, 

68 
test for qualitative, 68 
quantitative, 68 
chloroform in, tests for, 109 
cholesterin in, 50 
chromogens in, 40 

chrysophanic acid in, tests for, 52 
color of, 30 

copaiba in, tests for, 109 
corpora amylacese in, 132 
cotton fibres in, 134 
crystalline deposits in, 114 
cylindroids in, 131 
cystin in, 50 

tests for, 105 
in cystitis, 153 
in diabetes insipidus, 153 

mellitus, 153 
diacetic acid in. 47 
tests for. 100 
Arnold's, 101 
Gerhardt's, 100 
diazo reaction with, 50 
drugs in, 52 



Urine, drugs in, tests for, 107 
echinococcus in, 133 
eustrongylus gigas in, 133 * 
examination of, general routine, 142 

small amount of, 146 
fat in, 49, 132 

tests for, 104 
ferments in, 40 
tests for, 66 
in fevers, 152 
fibrin in, 45 

tests for, 82 
filaria in, 133 

functional efficiency of, 147 
gases in, 37, 52 
tests for, 107 
glucose in, 46 
glycuronic acid in, 41, 47 

tests for, 98 
gonococci in, 137 
in gout, 153 

hemoglobin in, 48 
tests for, 101 
aloin, 102 
Donogany's, 102 
guaiacum, 102 
Heller's, 102 
hippuric acid in, 39 

tests for, 64 
histon in, 45 

tests for, 82 
homogentisinic acid in, 50 
indican in, 40 

test for, qualitative, 66 
quantitative, 66 
ingredients of, inorganic, 37 

organic, 36 
inosite in, 47 
intestinal disease, 152 
iodides in, tests for, 108 
iron salts in, 42 
kreatinin in, 38 

tests for, 64 
lactic acid in, 51 

tests for, 106 
lactose in, 46 
tests for, 97 
Buhner's, 97 
Lea's sugar in, 47 
tests for, 98 
lead in, tests for, 107 
leucin in, 50 

tests for, 104 
leucocytes in, 126 
counting of, 126 
in leukemia, 153 
levulose in, 46 
reaction for, Seliwanoff's, 98 
tests for, 98 
in liver disease, 153 
lycopodium in, 134 
maltose in, 47 
tests for, 98 



IXDEX. 



333 



Urine, melanin in. 48 

tests for. 102 
mercury in. tests for. 107 
micrococcus ureae in. 141 
microscopical examination of. 113 
molecular concentration of. 34 
morphine in. tests for. 109 
mucin in. 45 

naphthaline in. tests for, 109 
neutral sulphur in. 41 

tests for. 68 
nitrates in. 42 
nubecula in. 30 
nucleo-albumin in. 45 
tests for. 81 

histon in. 45 
odor of. 31 

orthoform in. tests for. 109 
osmotic pressure of, 34 
oxalic acid in, 40 

tests for. 65 
oxaluric acid in. 40 
parasites in. 132 
pentose in. 47 

tests for. OS 

Bial's. 08 

peptone in. 45 

tests for. 80 
phenacetine in. tests for. 109 
phenol in. 41 

tests for. 106 
phosphates in. 42 

test for. qualitative, 70 
quantitative. 70 
physical properties of. 29 
pigments in. 40 

tests for. 66 
potassium chlorate in. tests for, 108 
preservation of. 113. 142 
prostatic elements in. 132 
ptomains in. tests for. 107 
purin bases in. tests for. 63 

bodies in. 39 
in pyelitis. 153 
pyogenic cocci in. 138. 140 
pyramidon in. tests for. 109 
reaction of. 33 

methods of determining. 33 
in renal disease. 152 
resorcine in. tests for. 110 
retention of. 29 
salicylic acid in. tests for. 108 
santonin in. tests for. 108 
secretion of. 17 
sedimentation of. 113 
in sepsis. 113 
serum globulin in. 44 
-katol in. 40 

skatoxyl in. tests for. 106 
specific gravity of. 31 

determination of, 32 
spermatozoa in. 131 
starch in. 134 



Urine, in stomach disease. 152 
sugar in. 45 

delicacy of. tests for. 93 
differential density of. method of 

determining. 96 
estimation of. Beck's. 94 
Citron's. 94 
Fehling's. 93 
Knapp's. 05 
separation of. from urine, 93 
tests for. Briicke's, 84 
Fehling's. 85 
fermentation. 90, 97 
f urfurol. 89 . 
heating. 88 
Hoppe-Seyler's. SO 
Horsloy-Pratesi's. 89 
Maschke's. 85 
methylene blue test, 88 
Moore's. 87 
Xvlander's. 83 
Penzoldt's. 89 
phenylhydrazine, 02 
picric acid. 88 
polariscope. 01. 07 
qualitative. S3 
quantitative. 03 
Buhner's. 87 

sodium sulpho-indigotate, 88 
Trommer's. 86 
sulphocyanides in. 41 
sulphates in. 41 
conjugate. 42 
ethereal. 42 
mineral. 41 
pre-formed. 41 
sulphonal in. tests for. 109 
suppression of, 29 
in suppurations. 153 
in suppurative nephritis. 153 
tannic acid in. tests for. 109 
taurocarbaminic acid in. 41 
testicular casts in. 132 
toxicity of. 140 
trional in. tests for. 100 
trichomonas vaginalis in, 132 
in tumors. 152 
tumor-particle^ in. 132 
turpentine in. tests for. 100 
in typhoid. 130 
t^rosin in. 50 
* tests for. 104 
urea in. 37 
uric acid in. 38 
urobilin in. 48 

tests for. 103 
urotropine in. tests for. 100 
volatile acids in. 51 

fatty acids in. tests for. 107 
xanthin bases in, tests for. 63 

bodies in. 30 
yeast in. 141 
Urine-srlucosometer. Stern's. 07 



334 



INDEX. 



Urinometer, 32 

Urino-pyknometer (Saxe's),32 
Tjrobilin in urine, 48 

tests for, 103 
Urochrome, 66 
Uroerythrin, 66 
Urotoxy, 150 
Urotropine in urine, tests for, 109 

V 

Vascular changes in kidney, 24 
Vegetable detritus in feces, 191 
Vegetables, green, as food, 199 
Volatile acids in urine, 51 

W 

Wassiliew's estimation of albumin, 

78 



Weil's bacillus, 226 
Will-Varrentrapp's method for nitro- 
gen, 55 
Worms, cestodes, 282 



Xanthin bases in urine, tests for, 63 
bodies in urine, 39 
form of crystals, 119 



Y 

Yeast in urine, 141 



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